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Black Youths Seniors Connect Program Registration
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Black Youths Seniors Connect Program Registration
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Participant Information
*
First
Last
Email
*
Phone Number
*
Date of Birth
*
Age Group
Under 12
13-17
18-24
25-35
36-45
46-60+
Gender
Select
Male
Female
Other
Address
*
City/Province
*
Select Your Program(s)
Seniors Program
Youth Programs
Permission & Agreement
*
I agree and give my permission
I acknowledge that the information provided is accurate. I agree to abide by the program rules and give permission for Black Youths Seniors Connect (BYSC) to use photographs and videos of me during events for promotional purposes.
Submit Your Registration
