Youth Membership Form
Please fill out all required information in this form.
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
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Address (Street number, street name, apartment (if applicable), city, province/state, country, postal code/zip code) *
Your answer
Phone Number *
Your answer
E-Mail Address *
Your answer
Health Insurance Number (Medicare Card)
Your answer
Gender *
Name of Parent/Guardian *
Your answer
Relationship to Youth Member *
Your answer
Emergency Contact Number *
Your answer
Name of School *
Your answer
I have read my rights as a member of the Lennoxville Youth Center. By clicking "yes" you acklowledge that you have read and understand your rights as a member. (You will be asked to sign a physical sheet.) *
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I have read my responsibilities as a member of the Lennoxville Youth Center. By clicking "yes" you acklowledge that you have read and understood your responsibilities as a member. (You will be asked to sign a physical sheet.) *
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I understand that by filling and sending this form does not guarantee my membership at the Lennoxville Youth Center. I understand that I must present myself at the Lennoxville Youth Center within 7 days for my membership to become active. By clicking "yes" you understand and agree to the above terms and conditions. *
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