25/26 Rainbow Coffee House
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Name (you go by)
*
Date of Birth
*
Pronouns
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Youth Email
*
Youth Phone
*
Home Address
*
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Are your parent(s)/legal guardian(s) aware of your queer identity?
*
Do you have any allergies or medical concerns we should be aware of?
*
I acknowledge that I am currently under the age of 18 years old.
*
Please select all that apply.
Yes, under 18 years of age
Emergency Contact
In the case of an emergency, RCH needs to have a safe person for us to contact. Please provide information about a safe adult in which we can contact if the need arises.
Name of Emergency Contact (Must be 18+)
*
Emergency Contact Phone Number
*
Name that Emergency Contact knows you as?
*
Is your emergency contact aware you are attending RCH?
*
PLEASE NOTE! Rainbow Coffee House is expressly for Middle and High School age students, Grades 7-12. ALL participants MUST be under the age of 18 at the beginning of the school year.
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Description
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