Youth Journeyz Online Program Registration
Starting Date : September 11th, 2023
Location: 970  Madison Square Madison, TN 37115
Contact us at (615) 905-6295 or youthjourneyz@yahoo.com
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Email *
Child’s name (Last, First, Middle) & Name student would like to be called *
Students Date of Birth *
MM
/
DD
/
YYYY
Student ID #(If MNPS Student)
 *
Gender *
2023-2024 School Year Grade *
  Child’s Parent/Guardian name and Contact 
 *
I give my permission for any of the following individuals to be contacted and my child may be dropped off/released to any person listed
 *
These additional individuals also have permission to pick up my child:
*
  Parent/Guardian signature:   _________________ 
Date: _________________  
 *
The best number to contact you at 
When your child is in our care 
cell phone #: 
home phone #: 
alternate phone #:
 *
In an emergency, if you are not able to contact me, contact the following: 
(*List First and Last Names, Cell phone, home phone, alternative phone numbers)
 *
Child’s Health Information: 
Child’s medical care provider 
or Parent’s/guardian’s preferred 
Medical facility for treatment 
Name: 
Phone: 
Street Address: 
Child’s last physical exam, if available:  
 *
Child’s Health Information: 
Child’s Dental Care Provider 
or Parent’s/guardian’s preferred 
Dental facility for treatment
Name:
Phone:
Street Address:
Child’s last dental exam, if available  
 *
Known health conditions:
(An individual care plan from child’s health care provider is required for any food allergies or special dietary requirement due to a health condition.) 
(Please add information in detail below and submit proper documentation with final application during registration)
 *
What days will your child attend? *
Required
Dietary restrictions *
I am aware that Youth Journeyz Aftercare Program
has a $65.00 weekly charge. And payments are required by Friday prior to each week.
I am responsible for all expenses related to camp fees (e.g. registration, late fees, etc.) and understand that depending on eligibility and funding availability my child may also qualify for scholarships and/or prorated discounts.
 *
Required
A copy of your responses will be emailed to the address you provided.
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