Clinton Youth and Family Service Bureau
Program Sign Up Form 2010
Name of Youth
Age
Grade entering fall 2010
Address
Program Titles you're interested in signing up for:
Parent / Guardian Name:

How would you like us to contact you

Contact Email Address
(optional)

Home phone

Business Phone

Cell Phone

Best Number for a day time contact

Comments & Questions you may have Below

PLEASE RETURN WITH APPROPRIATE FEE TO: Clinton Youth and Family Service Bureau, 112 Glenwood Rd., Clinton, CT 06413

Total Fee:

We will be unable to contact you unless all information is filled in properly !!

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