Required fields are marked with asterisks (*)

Youth Room Card Application

This form is for students in Grade 6-12 wishing to have access to the Youth Room.

Participant Name

Address

City or Town

Province

Postal Code

Phone Number (Main)

Grade (Must be grade 6-12)

E-mail Address

Parent or Guardian Name

Parent or Guardian's Phone Number (Main)

I confirm the participant is in grades 6 - 12.

Yes

Today's Date

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