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____________________