Us Against Abuse        148 Ithaca St.,  Bay Shore, NY 11706                                      Phone: 516-456-1039    Fax: 530-869-5639 •ZClique• Listen. Learn, Love … Club for , by and about kidZ guided by caring adult facilitators. Empowering and encouraging youth to think, act and make wise decisions & choices. Respect, Restraint & Responsibility along with developing life, business & entrepreneurial skills as it’s main focus. Team building 4 Life •Communication Wave The Power to shape the future!” A multi-media center that creates projects to foster understanding with hands on experience in a real studio and community radio station. Training in multi-media, audio, video, & other art forms. Watch for RXA community radio…. JOIN US and be part of being a Dream BELIEVER & RECEIVER!                                                        ZClique Membership Form

Please print and complete it, then mail to the address above                                  to print just the form highlight it go to file print and click selection

 NAME__________________________________________________________________

Present Age_________ Date of Birth_____________

Achievement’s, Hobbies_____________________________________________________________________________

Address___________________________________________________________________

Email____________________________Phone________________________Fax___________

 

I agree to be part of ZClique(Young Ambassador TEAM) and grant permission for  my ideas, story and photograph(s) to be published and displayed in  any Us Against Abuse Project: (Books, Magazines, Newsletters, Website, Calendars, Posters, Exhibits, Radio & Television Programs, etc.) created by Us Against Abuse) Organization agrees to give credit in proper manner at all times.

Anyone under 21 must  have consent below signed

 

Kid's Signature________________________________________________________Date_________________
 

PARENT'S / GUARDIAN'S NAME____________________________________________________________________

Address____________________________________________________________________________

Email____________________________Phone________________________Fax____________________

I grant permission for  my child to participate in Zclique and the use of material as above stated.
 
Parent's / Guardian's Signature
(Required if nominee is now under 21)

_____________________________________________Date____________________