Children & Youth Interest Form

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Parent/Guardian Name

Address

Parent/Guardian Cell Phone

Child's Name

Parent/Guardian Email

Child's Age

School Child Attends

Which program(s) ar you interested in: * Required

Creation Station

L5 (Fulton School Only)

Project Rediscovery (In-School Program Only)

Girl's Life (In-School Program Only)

Hockey

Recreation

Take Your Son/Daughter to Work

Hoop-It-Up

Day Camp

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6140 STATION STREET

PITTSBURGH, PA 15206

East End Cooperative Ministry is a 501(c)3 nonprofit and an Equal Opportunity Employer. EIN: 23-1722988

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