Youth 360 Community-Based Activity Stipend Program – Interest Form for Spring/Summer 2022

Please fill out this interest form to indicate which activity your student would like to enroll in.

Questions? Please call 373-3613.

* Youth Name
* Grade Level
* School Attending
* Parent/Guardian Name
* Primary Phone
* Parent/Guardian Email
* How would you like to be contacted?
Alt. Phone
Youth Phone (optional)
* Which activity would you like to enroll your student in?
If you're signing up for stipends for a school-based activity, please list the activity below.
Are there other activities you'd like to see offered through our stipend program?

Parent/guardian responsibilities:

I understand that I am responsible for completing any additional paperwork or requirements from activity providers, and for working to make sure my child attends activities as scheduled. I understand that repeated no-shows may make my child ineligible for future Youth 360 stipend programs. I understand that my child’s participation in these activities is taken at my own risk and that Youth 360 is not responsible for the well-being of my child while participating in vendor-provided activities. I agree to complete a short post-activity survey to help Youth 360 determine activity quality. 

By electronically entering my name below, I acknowledge that I have read the above information and am agreeing to the responsibilities listed therein. I certify that no one has signed this form for me, and understand that this electronic signature is considered official by Youth 360, United Way of Mat-Su and their partner vendors.

* Parent/Guardian Signature