Pitstone Youth Cafe

Username *

Email Address *

Password (please type it twice) *

password strength indicator

First Name *

Last Name *

Adult emergency contact information

Adult mobile phone *

Home telephone

Town or Village Name *

Details of first young person

Full name of first child *

Young person date of birth (dd/mm/yyyy) *

Important information we need to know (medical etc)

Details of second young person (optional)

Full name of second child

Young person date of birth (dd/mm/yyyy)

Important information we need to know (medical etc)

Additional information

Relationship to children - If Other, please provide details below *

Please tell us any other information including additional young people

Member options

We have read and understood the information about the cafe

I would like to volunteer occasionally at youth cafe

Contact me by phone or text *
Yes No

Contact me by email *
Yes No

Photograph permission for club purposes *
Yes No

Video permission for club purposes *
Yes No

Registration confirmation will be emailed to you.