Youth/ Child Registration for Groups

Indicates required field

Note: If the youth/ child involved is a participant in a partner organization program taking at a partner site, you do not need to complete this form on their behalf.

The primary group contact needs to complete this form. Do NOT let the youth/ child complete this form. If you have questions, please contact source@jhsph.edu or call (410) 955-3880.

Name of JHU Group

School Affiliation of Group

If you answered 'other' in the above field, please explain here:

YOUR Email Address

Individual Youth/ Child Information

Full Legal Name of Youth/ Child (enter name exactly as it appears on official documents):

Youth/ Child Email

Youth/ Child Primary Phone Number

Youth/ Child Age as of Today's Date (if you know specific birth date, enter here--if not, age is acceptable):

Gender (optional)

Race (optional)

Permanent Address - Number/ Street (include apartment # if applicable)

City

Zip Code

State

Emergency Contact Information

Parent/ Guardian Full Name (first and last)

Parent/ Guardian Full Address (number, street, apartment, city, state, zip):

Parent/ Guardian Email Address

Parent/ Guardian Primary Phone Number

Parent/ Guardian Secondary Phone Number

Questions/ Comments

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