YOUTH REGISTRATION FORM

If you have any questions concerning this registration form or general questions about the Summer Youth Works Program, please contact Artiffany Stanley at

478-277-5059 or email stanleya@dlcga.com

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Date of Birth * +

Email Address *

Gender *

Male

Female

T-Shirt Size *

Primary Language *

English

Spanish

Bilingual

Other

Are you at least 16 years of age, or will be 16 by May 30, 2019? *

Yes

Do you have reliable transportation? *

Yes

School *

Do you have any scheduled vacation plans this summer? *

Yes

If yes, vacation start date +

If yes, vacation end date +

Do you have a criminal history? Having a criminal history does not disqualify you. *

Yes

If yes, select one of the following:

Violent

Non violent

Do you have a valid drivers license or state ID? *

Yes

Are you willing to participate in an initial drug screening? *

Yes

Type of summer work interested in *

Report abuse