ReFresh Kidz Registration Form

ReFResh kidz Youth Empowerment Program

Please complete the registration form for child(ren) to participate in our youth creative arts empowerment & mentoring program.

* Indicates required field

Participating Youth Name *

First

Last

Age *

Parent/ Guardian Contact Information

Parent/Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Emergency Contact

In case of emergency, please provide emergency contact information the participating child.

Emergency Contact 1 Name *

First

Last

Emergency Contact 2 Name *

First

Last

Phone Number *

Medical Information

Please provide any health/medical information for the participant.

Medical Information *

Allergies *

Approved Pick Ups

Approved Pick Up Name 1 *

Relationship to Participating Youth *

Approved Pick Up Name 2 *

Relationship to Participating Youth *

Approved Pick Up Name 3 *

Relationship to Participating Youth *

I agree to receiving marketing and promotional materials

Photo by Rafaela Biazi on Unsplash

ReFResh kidz Youth Empowerment Program

Parent/ Guardian Contact Information

Emergency Contact

Medical Information

Approved Pick Ups

The ReFresh Institute, Inc.

Email