Program Registration

Parent/Guardian Name *

First Name

Last Name

Child/Youth Name *

First Name

Last Name

Child/Youth Date of Birth *

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DD

YYYY

Parent/Guardian Phone *

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Name *

First Name

Last Name

Phone *

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Program *

Check all that apply

Be YOU! (for boys) - Monday, July 22nd

Art Day - Tuesday, July 23rd

My Emotions & Me - Wednesday, July 24th

I Shine! (for girls) - Thursday, July 25th - THIS GROUP WILL BE AT PORT HOPE LIBRARY

Beyond Books - Friday, July 26th

August 19th - Art Day

August 20th - Be YOU! - THIS GROUP WILL AT PORT HOPE LIBRARY

August 21st - I Shine! (for girls)

August 22nd - My Emotions & Me

August 23rd - Beyond Books

Where did you hear about this program?

Social media

Newspaper (online/print)

Radio

Website

Word of mouth

Email

By checking the box below, you are aware that the personal information shared in this form will only be used for the purpose of program registration and you agree to the disclosure of these details to Rebound's staff. *

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