Youth Registration Form

Thank you for your interest in participating in our Club Creative Workshops and/or Teen Summit group. This form is designed to capture all the necessary details to ensure a smooth and personalized experience for you or your teen.

Please enable JavaScript in your browser to complete this form.

Student Name *

First

Last

Student Name

First

Last

to (mm/dd/yy) (if

Date of Birth: (mm/dd/yy) *

Age *

Gender *

Male
Female
Non-Binary/Other
Prefer not to say

Email *

Home Address *

City/Town *

Phone Number *

Zip Code

Parent Guardian Name (if under 18): *

Parent/Guardian Contact Number: *

School Name *

Grade *

Emergency Contact Name *

Emergency Contact Phone Number: *

Are There Any Allergies, Health Concerns or Special Accommodations We Should Be Aware Of? *

Allergy List:

Program Interests & Needs *

Mentorship
Academic Support
Leadership Skills
Club Creative (Wednesday & Friday)
Conflict Resolution Skills
Young Voices Teen Summit Group (Coming Soon)
Emotional Support/Group Therapy

Do you need access to free tutoring? *

Any specific topics you'd like to cover in the program?

I give permission to On Her Throne to use photos/videos of me during program activities for promotional purposes. *

I understand and agree to fully participate in the program and follow all group guidelines. *

Parent/Guardian Signature (if under 18): *

First

Last

Todays Date: (mm/dd/yy) *

Thank you for taking the time to complete form.

Our team will review the information you provided and contact you to discuss the next steps.

If you have any questions or require further assistance, please don’t hesitate to contact us at
Admin@OnHerThrone.org or (508) 492-9998

We look forward to seeing you!
Warm regards,
On Her Throne, Intake Coordination

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18 School Street

Foxboro, MA 02035

(508)-492-9998

admin@onherthrone.org

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