Self Care Kickback Registration
Thank you for your interest in our Self Care Kick Back.  By completing this form you are requesting for us to contact you to discuss youth opportunities at South Side Help Center.
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Youth First Name *
Youth Last Name *
Student Age
What grade are you in?  *
What is you preferred method of contact?  *
Please submit your contact information for the above
Ex: If your preferred method is Text, input your text number. If it is WhatsApp, input your WhatsApp contact information. 
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Phone Number *
Parent/Guardian Email
Mailing Address *
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Este formulario se creó en South Side Help Center.