Child Registration | Youth Empowerment Zone

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Registration Informational Form

Parent/Guardian Last Name

Parent/Guardian First Name

Select an Address

Email

Phone

Choose Child Program

Contact Me By?

Phone

Email

Child Last Name

Child First Name

Select an Address

Birthday * required

School Grade For Fall

Parent Signature

Thank You For Registering Your Child. Our Team Will Be Back With You Within 24-48 Hours.

585-788-9083

1550 North Clinton Ave (Bastian Street Entrance)

Rochester, NY 14621

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