YLAC registration

MYLAC Registration Form

Participant information
Participant's Name:
Date of Birth:
Age:
Ethnicity:
Last school attended:
Grade level:
Email address:
Parent/Guardian Information
Parent or Guardian's name:
Address:
City:
State:
Zip:
Home phone:	( ) - Second three digits Last four digits
Alternate phone:	( ) - Second three digits Last four digits
Email:
Emergency Contact Information
Name:
Address:
Home phone:	( ) - Second three digits Last four digits
Alternate phone:	( ) - Second three digits Last four digits
Describe any medical problems, allergies, medications, or any conditions of the participant of which we should be aware:
Physician's name:
Phone:	( ) - Second three digits Last four digits
Essay Provide a 250-word essay that answers the question "Why do you want to be a member of MYLAC?"
Attach your essay:

City of Jacksonville