Youth Program Registration Form

Fields marked with are required.

Parent/Guardian Information

If registering more than one child, please submit one registration form per child.

Parent or Guardian's Full Name

Street Address

City

State

Zip Code

Primary Phone Number

Alternate Phone

Child's Information

What program are you registering your child for?

Child's Name

Gender

Date of Birth

Does your child have any allergies we should be aware of?

Parental Consent

I give my permission for my child to (check all the apply)

Have their photo taken during program activities

View a video/presentation that pertains to this program. (Animal Cruelty presentations may include some sensitive images depicting victims of cruelty)

How did you hear about this program?

Payment

** Please Note **

If the program you are registering your child for requires a payment, the payment in full is due 7 days prior to your scheduled program.

If we have not received your payment by the due date, your registration will be cancelled.

Payment Method

Pay with Credit Card by Phone

Mail Check (payable to Erie Humane Society)

Pay In-Person at the Erie Humane Society

Please verify that a real person is submitting this form