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College Outreach 2023

Please fill out the form below to enroll your student and send an $18.00 donation per student to help cover the cost of filling and mailing the care packages.

Your Student MUST be enrolled in our Young Adult Membership program to be part of Park's college outreach.

* If your student is NOT a YAM (Young Adult Member), select the second option to sign them up.

	My student is already a Young Adult Member	$0.00
	Sign my student up as a Young Adult Member	$72.00

* Student's Name

* Name of College

* Student's College Mailing Address

* Student is at the above address until the date: dd/mm/yyyy

* Student's Email

* Year in school

* Expected year of graduation

* Parent's Name

* Parent's Email

Comments

* Donation to help cover the cost filling and mailing the care packages:

$18.00

Please contact me about helping assemble the care packages

	Yes, contact me
	No, do not contact me

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total: