This information is required for youth without program staff. Our programming is supported by private grants and government contracts that require particular information to continue funding. Data collected below will be kept confidential.
If you have any questions, please contact Kristi Jeffers: or (978)927-8600.
Before you begin, please know you will need Emergency Contact and Health Insurance information for the applicant. At any time, you can save the form to be filled out later by clicking “Save and Continue Later” found at the bottom of the form.
If you prefer, you may download a PDF of this form to complete manually and mail to: Express Yourself, 100 Cummings Center, Suite 165-E, Beverly, MA 01915.