Whitin Community Center logo and Youth Outreach photos: Mentoring, Summer Theatre, youth, and youth center.
 
Youth Outreach Logo, Youth, Families, Community Working in Partnership.

Youth Outreach Registration Form

To register a child for any of the Youth Outreach Programs, please fill out the form below and click the button to securely send the registration form to the Outreach Director.

Or download the form and mail to Whitin Community Center, Attn: Monique Boucher, 60 Main Street, Whitinsville, MA 01588 or drop it off at the Rockdale Youth Center or the Whitin Community Center.
Also, download, complete and sign the following three (3) forms:

Parental Release and Authorization Form      • Youth Outreach Program Rules      • Discipline Policy

To apply to be a mentee, please also complete the Mentee Application.

Youth's First Name
Youth's Last Name:
Date of Birth:
Age:
Phone:
Address:
City, State Zip:
Email address:
School Attending:
Grade:
Allergies (please specify):
Medical Conditions (please specify):
Please List Medication(s) Currently Taking, if any:
Mother's Name: Day Phone:
Cell phone/pager: Email:
 
Father's Name: Day Phone:
Cell phone/pager: Email:
 
Child is in custodial care of: Mother    Father     Both     Other (specify)     
Which Youth Outreach Programs are you signing your child up for?   Please check all that apply:
Summer Youth Theatre Rockdale Youth Center
Saturday Afternoon Fitness & Fun Mentoring Partnership
In case of emergency, if parents cannot be reached:
Name: Relationship to Child:
Home Phone: Cell Phone:
Other Contacts/People permitted to pick up your child: (from any Youth Outreach programs that are in addition to parents/guardians listed above)
Name: Relationship to Child:
Address:
Home Phone: Cell phone:
 
Name: Relationship to Child:
Address:
Home Phone: Cell phone:
While at the Rockdale Youth Center
Do you give your child permission to be outside, in the rear of the
building only, with staff supervision for recreational purposes?
Yes      No
 
Do you give your child permission to briefly visit local stores
and restaurants in the neighborhood?
Yes (alone)  
Yes (only with another child)
No
 


Cancel/Return to Youth Outreach
 
Blackstone Valley Children's Place, Camp Whitin and Youth Outreach
programs are all affiliates of the Whitin Community Center.
  Monique Boucher, Outreach Director
508.234.8184 x 121

Fax:508.234.0625

Mailing Address: 60 Main Street, Whitinsville, MA 01588
Rockdale Youth Center: 57 Church Avenue, Northbridge MA 01534
Blackstone Valley Children's Place Camp Whitin Youth Outreach