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Empowering Youth Inc. Director: Katrina Martin

Please add a new child. You must complete an application for each child.

First Name *

Last Name *

Gender *

Date of Birth *

What is your desired schedule?

Schedule *

Days of week *

Drop off time *

Pick up time *

Monday

Tuesday

Wednesday

Thursday

Friday

Start Date *

Any comments regarding desired schedule?

How much more, if anything, would you be willing to pay for priority placement on a waitlist?

I wouldn't pay more A small amount (2%) A moderate amount (5%) A higher amount (20%) Other