Enrollee Information

Youth

Parent Name 1

Parent Name 2

Address*

Contact Info

Medical Information for Enrollee

ACCESSIBILITY: Brothers on the Rise and The City of Oakland Office of Parks and Recreation is fully committed to compliance with provisions of the Americans with Disabilities Act. Please direct all inquiries concerning program and disability accommodation to the BOTR Program Coordinator at (510) 928-4814 or mail to:cesar@brothersontherise.org. Please describe below special accommodations you or your child need to participate:

Other Emergency Contact

Name

Phones

Oakland Fund for Children and Youth (OFCY) Required info: