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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
*
Ages 4-18 ONLY
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
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Emergency Contact 2 Name
*
First
Last
Phone Number
*
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
*
-Select-
Mother
Father
Sister
Grandparents
Brother
Aunt
Uncle
Cousin
Family Friend
Approved Pick Up Name 2
*
Relationship to Participating Youth
*
-Select-
Mother
Father
Sister
Brother
Grandparents
Aunt
Uncle
Cousin
Family Friend
Approved Pick Up Name 3
*
Relationship to Participating Youth
*
-Select-
Mother
Father
Sister
Brother
Grandparents
Aunt
Uncle
Cousin
Family Friend
I agree to receiving marketing and promotional materials
Register
Photo by
Rafaela Biazi
on
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Home
Our History & Vision
The ReFresh Institute
Meet our Faculty & Instructors
Course Catalog
TRI Scholastic Bulletin
Donation/Contributions
Scholar Support Services
ReFresh Global
>
ReFresh Evergreen Community Improvement Initiative
Store
Contact Us