Action Team Spring 2018 Registration Form
This form serves as a student registration for participation in Youth Community Service's middle school leadership after school program, Action Team for the Spring 2018 semester.

Action Team will meet on Wednesdays from 4:00pm to 5:30pm at the Mitchell Park Community
Center in Palo Alto. This semester long program will start on January 17th and end on May 16th.

Please send a $160 registration fee along with filling out this registration form. Checks can be made out
to “Youth Community Service" and mailed to 705 Alester Ave. Rm 4, Palo Alto, CA 94303. *Scholarships are available.*

Thank you for your support of Youth Community Service and student service-learning. For more information about YCS, visit us at www.youthcommunityservice.org or check out our Facebook page!

Questions regarding this form may be submitted to Lori, at lori@youthcommunityservice.org.

*Note: This program used to be called SWAG (Students With A Gateway)

Student's School *
Student's Grade *
Student's Full Name *
Your answer
Student's Home Address *
Your answer
Home Phone Number *
Your answer
Student's Birth Date *
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DD
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YYYY
Parent/Guardian Contact Name *
Your answer
Parent/Guardian Email Address *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian Employer *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
I, the parent/guardian of the above-named student, give permission for my child to participate in YCS program activities, including associated travel sponsored by Youth Community Service. In consideration of participation in this program, I hereby hold harmless Youth Community Service (YCS), its agents, employees and volunteers, from any injuries, accidents or losses, however caused, related to attending the activities, and agree to release all parties involved from any claim, lawsuit or damage which may arise as a result of or by reason of any injury, loss or accident. *
Type your name below to give permission:
Your answer
I give my permission for YCS to use my child's picture, artwork, written work, and quotes for promotional materials. *
I am interested in volunteering at YCS activities.
Volunteering activities could include set up, chaperoning, running activities, etc. We will email you as needs arrive throughout the school year.
How did you hear about Action Team?
Your answer
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