YouthChildRegistration

Youth/ Child Registration for Groups. Note: If the youth/ child involved is a participant in a partner organization program taking at a partner site, you do not need to complete this form on their behalf.

The primary group contact needs to complete this form. Do NOT let the youth/ child complete this form. If you have questions, please contact source@jhsph.edu or call (410) 955-3880.

Name of JHU Group*

School Affiliation of Group*

If you answered 'other' in the above field, please explain here:

YOUR Email Address*

Individual Youth/ Child Information

Full Legal Name of Youth/ Child (enter name exactly as it appears on official documents):*

Youth/ Child Email

Youth/ Child Primary Phone Number

Youth/ Child Age as of Today's Date (if you know specific birth date, enter here--if not, age is acceptable):*

Gender (optional)

Race (optional)

Permanent Address - Number/ Street (include apratment # if applicable)*

City*

Zip Code*

State*

Emergency Contact Information

Parent/ Guardian Full Name (first and last)*

Parent/ Guardian Full Address (number, street, apartment, city, state, zip):*

Parent/ Guardian Email Address

Parent/ Guardian Primary Phone Number

Parent/ Guardian Secondary Phone Number

Questions/ Comments

SOURCE (Student Outreach Resource Center)

Audiences