Defy youth application
ESTATE BOVONI – TUTU HI-RISE WEED AND SEED GROVE PLACE WEED AND SEED Tel# 340-776-1525 STT 340-201-9097 STX YOUTH APPLICATION DRUG EDUCATION FOR YOUTH Coordinator Use Only Date Received: __________ Application #: ___________ Please type or print legibly – To be completed by Parent or Guardian Youth’s Name: __________________________________________ Age _____ DOB: ___/ ___/_____ Youth’s Address: _____________________________________________________________________ Youth’s Email Address: _________________________________________________________________ Name of Youth’s School: ______________________________________________________________ Last Grade attended________________________ Promoted ________________ Retained ____________ Father’s Name: _______________________________________________________________________ Father’s Address: ___________________________________________________________ Work Phone: ( ) _______________ Home Phone: ( )_________________________ Email Address: ________________________________________________________________________ Mother’s Name: _______________________ …
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ESTATE BOVONI – TUTU HI-RISE WEED AND SEED GROVE PLACE WEED AND SEED Tel# 340-776-1525 STT 340-201-9097 STX YOUTH APPLICATION DRUG EDUCATION FOR YOUTH Coordinator Use Only Date Received: __________ Application #: ___________ Please type or print legibly – To be completed by Parent or Guardian Youth’s Name: __________________________________________ Age _____ DOB: ___/ ___/_____ Youth’s Address: _____________________________________________________________________ Youth’s Email Address: _________________________________________________________________ Name of Youth’s School: ______________________________________________________________ Last Grade attended________________________ Promoted ________________ Retained ____________ Father’s Name: _______________________________________________________________________ Father’s Address: ___________________________________________________________ Work Phone: ( ) _______________ Home Phone: ( )_________________________ Email Address: ________________________________________________________________________ Mother’s Name: _______________________________________________________________________ Mother’s Address: ________________________________________________________________ Mother’s Work Phone: ( ) __________ Home Phone: (____) __________________________________ Email Address: ________________________________________________________________________ Legal Guardian’s Name: _____________________________________________ Legal Guardian’s Address: _________________________________________________________ Guardians Work Phone: (____) _______________________________ Home Phone: (_____) __________ Email Address: ________________________________________________________________________ By my signature, I agree to make the youth applicant available for the Phase I Summer Leadership Camp and the Phase II School - Year Mentoring Component. I also agree to participate in any and all program measures of effectiveness studies, surveys, and questionnaires to further improve the quality of the Program. Signature ____________________________________ Date ___________________________