Youth Education and Sports Inc.
National Student Athlete Certification Program
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YOUTH EDUCATION AND SPORTS REGIRSTRATION FORM
APPLICANT NAME
APPLICANT DATE OF BIRTH
APPLICANT CURRENT ADDRESS
APPLICANT PHONE
APPLICANT EMAIL ADDRESS
APPLICANT CURRENT SCHOOL
APPLICANT CURRENT GRADE
SHOOL PRINCIPAL
SCHOOL PHONE NUMBER
EMERGENCY CONTACT NAME
EMERGENCY CONTACT RELATIONSHIP
EMERGENCY CONTACT NUMBER
EMERGENCY CONTACT ADDRESS
PARENT NAMES
PARENT PHONE NUMBERS
PARENTS DATE OF BIRTH
PARENTS CURRENT EMPLOYER
PARENTS EMPLOYER ADDRESS
PARETNS WORK PHONE NUMBER
PARENTS EMAIL ADDRESS
HOW LONG EMPLOYED
REFERENCES 1 + PHONE NUMBER
REFERENCES 2 + PHONE NUMBER
ADDITIONAL CHILDREN NAME 1
ADDITIONAL CHILDREN NAME 2
ADDITIONAL CHILDREN NAME 3
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****By clicking submit on this application; you authorize the verification of the information provided on this form as to my credit towards membership. You will receive a phone call from a member of our staff within 48 hours.***
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