Youth At The Center Application

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Applications are accepted on a rolling basis – 16 Spots will be filled as applicants apply so apply today!

Opening Retreat –March 28
$50 Stipend for Participants
8 Weekly Trainings March - May
This program will kick off with a youth retreat in early March, with weekly meetings after that culminating in a final gathering and celebration May 5th to 13th

First Name *

Last Name *

Age *

School *

Grade *

Home Phone *

Cell Phone *

Can you text on your cell phone?

Yes

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Email Address

What is the best way to reach you? *

Cell Phone

Home Phone

Required

Home Address, City, State, Zip Code *

Date of Birth *

YYYY

Other Languages Spoken *

Ethnicity

Gender

Are there any additional aspects of your background or identity that you would like to share?

Are you involved in other extracurricular activities, groups, sports, etc? Please list them below.

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