STMSTV Registration Form

Childs Name:

Email Address:

Guardians Name:

Phone:

Address:

City:

State:

Zip:

Please Choose a Program Boys 2 Men Program A Girls Life Program

Age 11 12 13 14 15 16 17 18 19

Gender Male Female

Race African American/ Black Asian Caucasian/ White Hispanic/ Latino Indian Native American/ Indian Other

Emergency Contact Info

Name:

Phone:

Address:

City:

State:

Zip: