After-School Youth Program Registration – The Living Wells Community & Development Center

Parent/Guardian Name

First

Last

Parent/Guardian Phone Number

that Age noticed

Parent/Guardian Email Address

Youth Participant Name

First

Last

Youth Participant Age

School Name

Allergies, Medical Needs, or Important Notes

Is there anything you’ve noticed that your child could benefit from additional support or encouragement with?

Please share anything you feel comfortable noting, such as schoolwork, focus, confidence, peer interactions, or enrichment interests. This information helps us better support your child.

Required Typed Parent/Guardian Signature (Consent Verification)