Pact, An Adoption Alliance - Program Descriptions

Teen Club

Pact Teen Club Registration for the June 7th Tshirt Screenprinting Event in Oakland

Please fill out this form to register. You will receive more detailed information the week before the event.

(Please fill out a separate form for each Teen or Tween even if they are siblings.)

Youth Name:

Email Address:

Mailing Address:

City, State, Zip:

Home Phone:

Cell Phone:

Screen Name:

Birth Date:

Grade in Fall 2009:

Gender: Male Female

Race/Ethnicity:

Parent's Name(s):

Mailing Address:
(if different from child)

City, State, Zip:
(if different from child)

Home Phone:
(if different from child)

Cell Phone:

Email Address:
(if different from child)

Current Pact Family Member? Yes No

Are you already a Teen Club Member? Yes No

Please tell us who in your family will be attending:

Will parent attend parent group? Yes No

If you will need child care for children younger than 10, give us their information below:
Child Name & Birth Date

Child Name & Birth Date

Child Name & Birth Date

Please list any issues, concerns or ask any questions you may have here:

Youth Name:
Email Address:
Mailing Address:
City, State, Zip:
Home Phone:
Cell Phone:
Screen Name:
Birth Date:
Grade in Fall 2009:
Gender:	Male Female
Race/Ethnicity:

Parent's Name(s):
Mailing Address: (if different from child)
City, State, Zip: (if different from child)
Home Phone: (if different from child)
Cell Phone:
Email Address: (if different from child)

Current Pact Family Member?	Yes No
Are you already a Teen Club Member?	Yes No

Please tell us who in your family will be attending:

Will parent attend parent group?	Yes No

If you will need child care for children younger than 10, give us their information below:
Child Name & Birth Date
Child Name & Birth Date
Child Name & Birth Date

Please list any issues, concerns or ask any questions you may have here: