2019-20 PEC Youth Centre Member Registration
Welcome to the Youth Centre!
We're located at 299 Main Street, Picton.

With this registration, you will be included on ROC e-info shares for Youth Centre programs, events and opportunities.

With this registration, you give media consent for any images/video/recordings taken of you to be used for media purposes, including both traditional and digital or social promotional presentations and marketing campaigns.

* Required
Member Information
First Name *
Your answer
Last Name *
Your answer
What gender do you identify with? *
Date of Birth *
MM
/
DD
/
YYYY
Age: *
Your answer
What grade are you in? *
Choose
7
8
9
10
11
12
Victory Lap
Your Contact Number *
Your answer
Is this a cell / text number? *
Choose
Yes
No
Your Email Address *
Your answer
What town are you from? *
Clear selection
*
Parent/Guardian Information
Parent/Guardian Name (First & Last): *
Your answer
Phone Number: *
Your answer
Parent/Guardian Name (First & Last):
Your answer
Phone Number:
Your answer
Emergency Contact Information
Emergency Contact Name *
Your answer
Relationship to you: *
Your answer
Emergency Contact Phone Number: *
Please provide a number where they can be immediately reached (Example: cell phone)
Your answer
Additional Information
Have you participated in ROC programs before? *
Were you a Youth Centre Member last year? *
If you answered "Yes" to either of the questions above, what is your reason for returning to the Youth Centre? (Feel free to add your own answer!) *
Required
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This form was created inside of ROC (Recreation Outreach Centre).