Ithaca St., Bay Shore, NY 11706
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!
Please print and complete it, then mail to the address
to print just the form highlight it go to file print and
Present Age_________ Date
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.
under 21 must have consent below signed
/ GUARDIAN'S NAME____________________________________________________________________
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)