Youth Activity Center Membership Registration Form
Child's Name *
Your answer
YAC Membership Number
Your answer
Mailing Address *
Your answer
Parent/Guardian Name 1 *
Your answer
Parent/Guardian Name 2
Your answer
Parent Phone Number 1 *
Your answer
Parent Phone Number 2
Your answer
Parent Phone Number 3
Your answer
Parent Phone Number 4
Your answer
Parent's Place of Work *
Your answer
Parent's e-mail address 1 *
Your answer
Parent's email address 2
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Gender *
Grade for 2018-2019 School Year *
Child's School *
Emergency Contact Name (other than parent) *
Your answer
Emergency Contact Phone Number *
Your answer
Child's Doctor
Your answer
I have read the Membership Information Packet and understand the YAC rules and policies. *
Required
The use of photos and videos taken of YAC activities is of great importance to the YAC and Los Alamos Family Council. I give permission to the YAC to use these relevant photos and videos. *
By typing my name in the field below, I am providing my signature. *
Your answer
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