EVYP Youth Membership Application

EVYP Youth Membership Application

East Village Youth Program prepares Chicago youth to become first generation college graduates.
Youth Member Information
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Youth Cell Phone Number *

- Area Code Phone Number
Email *
example@example.com
Birthdate *

- Month - Day Year
Date
Gender *
Ethnicity (choose all that apply) *

American Indian or Alaska Native Asian Black or African American Hispanic/Latinx Native Hawaiian or Pacific Islander White

Release of Personal Information

By checking the box below, I hereby certify that I am willing to provide all of the personal information asked for in this application as well as personal records. I understand that this information will be kept confidential and will be used for internal organizational purposes and not shared with any third parties.
Release of Personal Information *

Yes

Should be Empty: