Registration Form
Welcome to The BREAK! Please fill out the following information. Make sure you select submit form before closing the window.

*Might need to scroll up after hitting next to the access the next forms.
Legal first and last name of member *
What is the member's preferred name?
Date of Birth *
MM
/
DD
/
YYYY
Age *
What is your primary language? *
Guardian's Name
Guardian Phone Number
Guardian Email
Are you an alumni? (Attended the as a teen and now a young adult) *
Are you new to The BREAK? *
School *
Grade *
Gender *
Ethnicity *
Address (# and street name) *
Address (City) *
Address (State and Zip code) *
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone Number *
Member phone number
Member email
Any medical history or allergies staff should be aware of? (If no, skip the next question) *
What medical history or allergies staff should be aware?
Disabilities diagnosed with: (check all that applies) *
Required
Where did you hear about The BREAK? *
Required
Name of referral, member, or organization
What are your interest? (Check all that applies) *
Required
Are you applying for financial assistance? *
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