JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
L.U.C.K.Y. Mentoring Program Registration 2021-2022
* Indicates required question
Name of future l.u.c.k.y. parent
*
Your answer
Name of future L.U.C.K.Y. girl/ teen
*
Your answer
Parent Phone Number
*
Your answer
Parent Email
*
Your answer
Family Address for L.U.C.K.Y. girl/teen
*
Your answer
How old is your child?
*
Your answer
What grade is your L.U.C.K.Y. girl/teen in?
*
Your answer
Select location.
*
Mallery/ Rumph Recreation Center 100 East Johnson Street
Community Center at Visitation 2646 Kensington Ave
Cecil B Moore Recreation Center 2551 N 22nd Street
Virtual Only
During the program, we may take photos/videos/audio recordings of participants to use in promoting L.U.C.K.Y. Mentoring Program Organization in general. Do you consent to your child being photographed or recorded by us for the above purpose?
*
Yes
No
Please select any known allergies of your child/teen.
*
Nut Allergy
Lactose Intolerance
Gluten Intolerance
Other:
Required
Emergency Contact Name:
*
Your answer
Emergency Contact Phone Number
*
Your answer
Emergency Contact Address
*
Your answer
How did you find out about the L.U.C.K.Y. Mentoring Program
*
L.U.C.K.Y. Email Newsletter
L.U.C.K.Y. Social Media
L.U.C.K.Y. Organization Member
L.U.C.K.Y. Website
Partner site i.e. CB Moore, Mallery or CCV
Does your child need any special accommodations of any kind?
*
Yes
No
Need help?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
