Youth Info Form 22/23
This form is so that we can have the information on the youth who participate in our youth program.  Please answer the questions below for youth.  Thank you for your entry
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First Name *
Last Name
Date of Birth
MM
/
DD
/
YYYY
Youth Phone number (if applicable)
(xxx) xxx - xxxx
Youth Email (if same as parent email please leave blank)
What Grade in school are you? *
Male/Female
Clear selection
Home Address
Parent/Guardian Name(s)
First and Last (please include mother, father, or guardian)
Parent/Guardian Phone Number
Parent/Guardian Email
We also ask for a facial photograph of the student for our database.
This photograph will be for the youth records only and will not be share with anyone except RHUMC staff.  The purpose of this is so that we can put a face with a name.  Please submit a current picture of the youth signing up with no obstructions to the view of the face.  You will be prompted upon completion of the form to email your picture.  
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