Partnerships for Youth at Risk > Registration > Youth Fire Starters

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Contact Us

Phone: 702.267.2284

Mail Stop: 133
P.O. Box 95050
Henderson, NV 89009-5050

Questions? Email Us!

IMPORTANT:
Parents and Guardians must register their child for the program online. They will be contacted by
the program and an appointment will be scheduled with each family. Referring agency may help
the family register online.

Parents or Legal Guardians must attend all classes with child

Limited class size, so please register early

All class dates & times subject to change

Registration Information

All information on this form is REQUIRED

Child's First Name:	Child's Last Name:

Child's Age:

Parent or Legal Guardian Full Name:

Home Phone or Contact Number, including area code:

Office or Mobile Phone Number, including area code:

Parent or Guardian Email Address:

Home Address

All information on this form is REQUIRED

Street Address:

City:

State:

Zip Code:

Do you require an interpreter? If so, what language:

Child's School Information

All information on this form is REQUIRED

School Name currently attending:

School ID#:

Referring Agency Information - Who sent you to this program

All information on this form is REQUIRED

Referring Agency:

Agency Contact
First Name:	Last Name:

Phone Number:

Email Address:

Date of Referral:

Reason for Referral:

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Partnerships for Youth at Risk
Mail Stop: 133
P.O. Box 95050
Henderson, NV 89009-5050

Phone: 702.267.2284
Email: info@partnershipsforyouthatrisk.org