Youth Alive Registration
Sept 2018 - Sept 2019
1650 Waddington Rd, nanaimo, BC V9S 4W3
Contact us at 250 753 0241
Email address *
Youth Name (First) *
Your answer
Youth Name (Last) *
Your answer
Grade *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Contacts (Home Phone) *
Your answer
Contacts (Your Cell)
Your answer
Home Address *
Your answer
Can we connect with you on Social Media? *
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