SBX/ListoAmerica Clubhouse Membership
To become a Clubhouse member please fill out the following and return a SIGNED copy of the Parent/Guardian consent form located at the end of this form (Clubhouse is for youth ages 12 - 18).

The Clubhouse program is a project pioneered by the MIT Media Lab and The Clubhouse Network, with over 100 branches all over the world! Our Clubhouse in Moreno Valley is a safe and fun place for young people to work with adult mentors, gain confidence, learn new skills, and express themselves through the creative use of technology. Come check us out!

Thank you for your interest and we will follow up with you shortly. All information is private and will not be used for marketing or be shared with anyone.  

*ListoAmerica is a licensed Clubhouse and offers the program through SBX: Youth & Family Services headquarters at 

12125 Day St. Suite E303
Moreno Valley, Ca 92557
P: 951-247-1700

Clubhouse Open Monday - Friday
1 PM - 6PM

Sign in to Google to save your progress. Learn more
Innovation Youth Lab at SBX: Powered by ListoAmerica & The Clubhouse Network
New Member Name *
Participant Date of birth *
MM
/
DD
/
YYYY
Parent or Legal Guardian Name
Parent or Legal Guardian Contact eMail *
Parent or Legal Guardian Contact Phone Number *
Participant email
Parent Guardian Consent Form
Please download, sign, and return the Member application and signed consent form to gmadrigal@listoamerica.org

APPLICATION AND PARENT/GUARDIAN CONSENT FORM LINK
(application can be filled out on computer, saved, and emailed) 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of ListoAmerica Inc..

Does this form look suspicious? Report

Google Forms