New Member ApplicationPlease complete the entire application. Gender Name * First Name Last Name Age * Date of Birth * MM DD YYYY Address * School * Graduation Year * Current Grade * Phone * (###) ### #### Member Email:(please provide a non-school email, school emails are blocked from receiving our emails.) * Parent(s)/Guardian(s) Email * Parent(s)/Guardian(s) Phone * (###) ### #### Any health/allergy concerns/diagnoses the you feel Ontario County Youth Court should be aware of? If yes, please list. (This will remain confidential)) * School Activities * Activities outside of school * How did you hear about us? * HAVE READ THE INFORMATION ON THE BACK OF THIS FORM REGARDING ONTARIO COUNTY YOUTH COURT AND UNDERSTAND THAT PARTICIPATION REQUIRES A ONE YEAR COMMITMENT AND THAT ALL CASES ARE CONFIDENTIAL. (please type signature and date below) * * I GIVE MY PERMISSION FOR THE MINOR NAMED ABOVE TO PARTICIPATE IN THE ONTARIO COUNTY YOUTH COURT PROGRAM. I ALSO CONSENT THAT ANY PHOTOGRAPHS OR FILM TAKEN OF MY CHILD MAY BE USED BY ONTARIO COUNTY YOUTH COURT WITH OR WITHOUT HIS/HER NAME FOR ALL USES WITHOUT RESTRICTIONS.(Parent/Guardian Signature and date typed below) * * Thank you!
