PRO Teen Registration and Permission Form
At PRO we offer a number of activities and opportunities for our youth to have FUN!

Safety is a high priority of ours so please fill out the below form and submit prior to your youth visiting the facility.

If you have any questions: Contact Robin Bruck at 603-235-0973 OR ROBIN.BRUCK@PROYOU.ORG

Email address *
(Youth) First Name *
(Youth) Last Name *
(Youth) Date of Birth *
MM
/
DD
/
YYYY
(Youth) Phone number *
Current School *
(Youth) Street Address *
(Youth) Town *
(Youth) State *
(Youth) Zip Code *
Parent/Guardian first name *
Parent/Guardian last name *
Parent/Guardian email address *
Parent/Guardian address (if different than above) *
Is parent/guardian above the emergency contact for the youth? *
Emergency Contact name (if different than parent/guardian)
Emergency Contact address
Emergency Contact email address
Emergency Contact best phone number
Emergency Contact relationship with youth
Does your teen have any allergies (food, environmental, etc)? Please provide details. *
From your point of view, what are the most important issues and difficulties that your teen faces? *
What are some things you would like us to know about your teen? *
Does your teen have any dietary restrictions? *
What are some favorite foods of your teen? *
In order to deliver our Teen program with no charge we are always looking for people or businesses to sponsor healthy food for this group. Do you have any interest in sponsoring this (usually the cost is about $100 per event)? *
Permissions-please check to confirm permissions: *
Required
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