Young Life Registration

Use the form below to submit an application for Hartford City Mission's Young Life Club.

In order to complete this application your parent/guardian will need to sign off on a hard copy of this application.
We will have a paper copy of your application ready to be signed by your parent/guardian when you arrive at the next Young Life club meeting.
Young Life Club is held at the North End Salvation Army, 100 Nelson St, on Tuesdays from 6:30-8:30.
If your parent/guardian is not available to sign during our Tuesday YL Club meetings they can stop by the HCM office, 280 Vine St, to sign it. However, they should call first, 860.246.0132, to make sure the application is ready.

Fill out the form below to start the registration process for Young Life.

Please note that you can only submit this form for children of whom you are the parent/guardian.

Parent/Guardian Information

* Indicates required field

Parent/Guardian Name *

First

Last

Parent/Guardian Relationship to Child(ren) *

Parent/Guardian Phone Number *

Number of Children Registering *

If you are registering more than one child, you will be redirected to an additional form to submit with each child's information. It does not matter what order you enter your children's information.

Parent/Guardian Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Church, If applicable *

How did you hear about HCM? *

Emergency Contact #1

Cannot be the parent/guardian

Emergency Contact #1 Name *

First

Last

Emergency Contact #1 Phone Number *

Emergency Contact #2

Cannot be the parent/guardian

Emergency Contact #2 Name *

First

Last

Emergency Contact #2 Phone Number *

Child Information

Name *

First

Last

Date of Birth *

Gender *

Female Male

School for 2019/2020 *

Grade for 2019/2020 *

Name of Teacher *

Allergies (food, bees, latex, nuts, etc). *

Please indicate what you do if your child comes in contact with their allergen (Epipen, hospital, benedryl, etc) *

Does this child have an IEP (Individualized Education Plan) or a 504 Plan? If so, we would like a copy so that we can do our best to follow your child's approved educational accommodations. *

List any medical conditions/needs that your child has. If none, put N/A. *

Are there any medications that your child takes that may need to be administered in an emergency. If so list them and why they would need to be administered. *

My child is able to arrive by 4:15pm *

Yes No

My child can attend all 5 days of program each week *

Yes No

Pick up Method *

T-Shirt Size *

Please add anything else we should know about your child here: *

Submit

Fill out the form below to start the registration process for Young Life.

Parent/Guardian Information

Emergency Contact #1

Emergency Contact #2

Child Information

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