Resilient Youth

REGISTRATION FORM

To be connected to a member of our team, please complete and submit a registration form:

Parent Name*

First Last

I am a* (Please select all that apply)

Service Member or Veteran

Family member of a Service Member or Veteran

Family of the Fallen

Military Branch* (If you're a family member, please indicate your loved one's military branch)

Service Status* (If you're a family member, please indicate your loved one's service status)

Are you currently serving as a military recruiter?

Yes

Parent Email Address*

Parent Best Contact Number (Area Code)-XXX-XXXX*

PHYSICAL Street Address*

Address

City* State*

Zip Code*

Child/Adolescent Name*

First Last

Child/Adolescent Date of Birth*

Child/Adolescent 2024/25 Grade in School*

Which of the upcoming session dates are you registering for?*

Mass General Brigham's standard is to send email securely via encrypted email. However, our website can only send unencrypted confirmation emails. If you would like an email confirmation, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Mass General Brigham will not be held responsible.

Please note that if you do not grant permission to receive unencrypted email, there may be a delay of a few business days in receiving your confirmation.

Permission to email unencrypted messages?*

Yes

How did you hear about us?