Z. Riley Center Application

Welcome to the Riley Center Application! All submissions are pending approval and once submitted we will be in touch! Don’t forget to check your mailbox!

The Riley Youth Center is a public, non-profit agency serving children and their families.

Parent or Guardian Name *Parent or Guardian Name

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

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Youth Center Location: *Select your location4040 W 71st Street Indianapolis, IN 462683445 Central Ave Indianapolis, IN 462052323 N illinois Street Indianapolis, IN 462085326 Hillside Ave Indianapolis, IN 462202424 Kessler Blvd E Dr. Indianapolis, IN 462205301 Roxbury Rd, Indianapolis, IN 462263351 W 18th Street, Indianapolis, IN 462265801 E 30th Street Indianapolis, IN 46218Indy Summer Learning LabYouth Center Location

Child's Ethnicity *Child's EthnicityAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteChild's Ethnicity

Choose Type of CareBefore and After SchoolSpring BreakSummer CampFall BreakWinter BreakSelect all that Apply

Child's Name

Child's Gender *MaleFemale

Child's D.O.B

Enter Child's Date of Birth

Your relationship to the childParent or legal guardianOther

Please specify your relationship to the child

Childs Age *5-11 years old - attending primary school11-14 years old - attending middle schoolAttendance Requirements

Which days would you like to book? *MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Comments *

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