Enrollment form

Welcome and congratulations on taking a big step in empowering and supporting your teen!

Please fill out these sections below:

  • Enrolling Youth Info
  • Points of Contact
  • Contact Preferences
  • Any Additional Comments
  • Consent / Liability

Enrolling Youth Info:

Teen's Name: (required)

Teen's Email Address:

Teen's Phone Number:

Teen's Birthdate: (required)

Any Medications: (required)
*if none please write none.

Any Known Allergies: (required)
*if none please write none.

Any special needs or strengths areas you would like to see more well empowered / engaged / supported?

Anything else that you feel is relevant to share about your youth?

Points of Contact

Mother / Guardian 1 Name: (required)

Parent 1 Email (required)

Parent 1 Phone


Father / Guardian 2 Name: (required)

Parent 2 Email (required)

Parent 2 Phone


Other Emergency Contact Name: (required)

Emergency Contanct Phone: (required)

Relation to Child: (required)
* legal guardian, family friend, grandmother, god-parent etc.

Contact Preferences

Administrative email:

what email address should we use to send you general program announcements: (required)

Non Emergency Primary Phone Number:

Main phone number to call first for non-emergencies: (required)


Mailing Address: (required)





Additional Comments:

Any other Comments you would like to make?

Consent:

 I / We agree

We, the Parent(s) / Guardian(s) will not hold The Moontribe or any of it's staff, members or youth mentors responsible for any accident or circumstance that may happen while our child is in The Moontribe program. If an accident does occur, we give The Moontribe staff our approval/ permission to take our child to the hospital to receive medical attention until we arrive. THE PARENT OR GUARDIAN IS RESPONSIBLE FOR HEALTH AND ACCIDENT INSURANCE. Please send a copy of both sides of your insurance card.

Sumitted By: (required)

Upcoming Events

  1. Weekly Empowerment Circle

    February 17 @ 3:30 pm - 6:00 pm
  2. Weekly Empowerment Circle

    February 24 @ 3:30 pm - 6:00 pm

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