Youth 360 Youth Club/Summer Program Registration

Youth Information

• * First Name:
• * Last Name:
• *

  Program Location Requested:

  • Houston
  • Wasilla
• * Student Date of Birth/Grade Level

• Please enter parent/guardian contact info below.

• * Email Address:
• * Confirm Email Address:
• * Phone:
• Cell Phone:
• Address 1:
• Address 2:
• City:
• State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• ZIP Code:

Additional Youth Information

• * Does the youth have any allergies? If yes, please list allergies in detail.
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• * Does the youth require any medications during program hours? If yes, please list.
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• Do you authorize Youth 360 to administer medications listed above during program hours?

  • Yes
  • No
• Gender:
• Other preferred names/nicknames:
• * Please list any other important information that will help us serve your child (medical conditions, special needs or other personal, health or safety information).
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Add other students from the same family below.

You may add a maximum of 10

Youth 360 has bus routes to/from central locations. Skip this section if rides are not needed.

• HOUSTON: Please indicate bus stop location(s) that would work for your family. We have additional stops; call 892-9495 for detailed route info.

  • Big Lake Three Bears
  • Pittman Road Three Bears
  • Houston Three Bears
  • Church Road @ Valley Country Store
  • Stanley Road/Parks Hwy.
  • None of the above

• WASILLA: Please indicate bus stop location(s) that would work for your family. We have additional stops; call 352-8379 for detailed route info.

  • Menard Sports Center
  • 3 Bears, Knik-Goose Bay Rd.
  • Lucus Rd./Nelson Ave.
  • Fairview Loop
  • None of the above
• If you selected "none of the above" and require transportation assistance, please indicate a location that would work for your child.

Additional Information (optional)

• Please share any info about the youth's interests, preferred activities, skills, talents and abilities. What would you like to see offered at Youth 360?
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• FAMILY ENGAGEMENT: Please let us know if you’re interested in volunteering at the program, connecting with other families, providing supplies, donations or program support, helping to spread the word in the community, or any other ideas!
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• Youth 360 is free to families, but we do accept donations to help with program operations. If you'd like to contribute, go to https://fundraise.givesmart.com/form/CSsZMA?vid=zqgpf. Don't forget to check the "Youth 360" box!

Parent/Guardian Info and Additional Contacts

• * Parent/Guardian Name(s)
• *

  How would you like us to contact you? Choose as many options as you like.

  • Phone
  • Text
  • E-Mail
• *

  Would you like to receive text updates about Youth 360 activities and programs? You can opt out at any time after joining. We share a text line (907-745-5826) with our partners at Thrive Mat-Su.

  • Yes
  • No
• * Please list names and phone numbers of at least two adults to contact in case of emergency if parents/guardians are unavailable.
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• Please list any additional adults approved to pick up your child(ren) from Youth 360.

• Approved Pick-up Person
• Approved Pick-up Person
• Approved Pick-up Person

• Youth 360 allows youth to depart the program site unaccompanied, with permission from parent/guardian. Do you authorize your child(ren) to leave the Youth 360 program site without an adult?

  • Yes
  • No
  • Please call me first

• IMPORTANT PERMISSIONS: By submitting this registration form, I agree to Youth 360 policies and procedures, and provide consent for my child(ren) to participate in Youth 360 activities and programs. I provide permission for Youth 360 staff to make decisions regarding the emergency medical care or treatment of my child(ren) if I cannot be reached. Youth 360 will conduct periodic private and anonymous surveys of participants and families in order to gather feedback and improve the program. Youth and families can choose not to complete surveys when distributed or offered. Youth 360 will utilize program photos, videos, youth-submitted media and artwork, social media outreach and other means to publicize the program and provide updates to families, participants and community members. If you do not want your child(ren)’s likeness or creative output used publicly, please contact Youth 360 Director at 373-3613 or director@youth-360.org.