Personal and Educational Enrichment Program (PEEP)

Registration Form

PERSONAL INFORMATION
Name (Last, First, Middle):	*
Address :	*
City	*
State:	*
County:	*
ZIP:	*
Cell Number:	*
Email Address:	*
Date of Birth (MM/DD/YYYY)	*
Age	*

PARENT/GUARDIAN INFORMATION
Parent/Guardian’s Name:
Address :
City:
State:
County:	*
ZIP:
Primary Home Telephone:
Cell Number:
Email Address:

BIOGRAPHICAL INFORMATION
Name of High School:	*
Grade :	*
Anticipated graduation date:	*
Plan to Attend College:		Yes No

SIGNATURES REQUIRED

Please indicate that you understand the following statements:
I give permission for my child to be photographed and for her photo to be used in promotional material.	*	Yes No
I understand that my attendance and participation at workshops will provide a valuable experience. If I desire to withdraw my participation in the Personal and Educational Enrichment Program, I must do so in writing to BYADC by June 19, 2021.	*	Yes No
APPLICANT:
Name:	*
Date:	*
PARENT:
Name:	*
Date:	*

Completed applications are due no later than Thursday, April 15, 2021 and can be e-mailed to byaorg1978@gmail.com.