Registration and Permission Form


At Austin17House we offer a number of activities and opportunities for our youth to have FUN!

Safety is a high priority of ours so please fill out the below form and submit prior to your youth visiting the facility. 

If you have any questions: Contact Director Lindsey Messina at 603 - 418 - 5864

Instructions: Please take the time to sit with your child and answer the following questions.

Youth Name *
Youth Name
Date of Birth *
Date of Birth
Youth Phone Number
Youth Phone Number
Youth Address
Youth Address
Parent Address
Parent Address
**if different than guardian address
Parent: *
i.e. food, medications, environmental, etc.
Social Media *
Social media (e.g., Facebook, Twitter) is a powerful communications tool. Austin17House (“AH”) expects all volunteers and partnered organizations abide by its social media policy in all their communications on any social media site. See button below** Do you give Austin17House permission to post and use photos of your child for marketing materials and social media accounts?
School or personal goals
Dietary restrictions, health concerns, etc.
Please check to confirm permissions