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Interested in your family participating in The Youth Connection's Virtual I2D2 Fit 'N' Fun Family Clubs? Please fill out the form below!

The information below is required to be in the program and your info will not be shared.

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* 1. Parent/Caregiver Full Name

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* 2. Home Address (Include city, state and zip code)

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* 3. Phone Number

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* 4. Age

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* 5. Date of Birth (ex 9.14.1971)

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* 6. Gender

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* 7. Race

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* 8. Email Address

Please fill out the information below for all children in household.

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* 9. How many children do you have?

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* 10. Children(s) Name(s) (include all children in household)

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* 11. Date of Birth(s) (ex 9.14.1971)

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* 12. Age(s)

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* 13. Male(s) or Female(s)

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* 14. Race(s)

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* 15. Our I2D2 Fit 'N' Fun Family Clubs program will be held virtually via Zoom. Are you familiar with Zoom?

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* 16. Do you have access to a computer with a webcam?

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* 17. Do you have reliable internet access?

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* 18. How do you access the internet?

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