Youth Development Programs Student Application Form

Complete this form to register your child for IMPACT CSC educational programs. In completing the application, the parent/guardian understands participation is voluntary. Activities and events can constitute student participation through digital engagement, classroom, and field trips. A parental consent form and other liability forms are required to grant permission for their child's participation in our programs. These forms are provided separately and submitted with the application. Note: An asterisk (*) on this form indicates a required field.

Student's First Name *

Student's Last Name *

Student's Phone Number *

Student's Birth Date +

Gender

Age *

Grade Assigned (check the applicable box) *

School the student attends

Anticipated Graduation Date

How did you learn about our programs?

Select the course or program you desire. *

Digital College/Career Preparation (Grades 6-12) - ongoing

Parent/Guardian's Name: *

Email *

Main Phone Number *

Secondary Phone Number

Address

City

State

Zip Code

Signature of Parent/Guardian *

clear

Date * +