Youth Development Program Application

Child Information

Child First Name *

Child Last Name *

Date of Birth

Gender *

Ethnicity *

Parent/Guardian #1 Information

Relationship to Student *

Parent/Guardian Name *

Home Phone *

Cell Phone *

Work Phone

Email *

Street *

City *

State *

ZIP *

Parent/Guardian #2 Information

Relationship to Student

Parent/Guardian Name

Home Phone

Cell Phone

Work Phone

Street

City

State

ZIP

Release of Child

My child will be picked up by the close of the program by me or the following individuals:

Name *

Relationship to Child *

Telephone *

Emergency Contact #1

Full Name *

Relationship *

Home Phone *

Cell Phone *

Email *

Emergency Contact #2

Full Name

Relationship

Primary Phone

Email

Consent Form

Permission for child to be photographed or recorded? *

Yes

No

Permission to participate in YMCA studies? *

Yes

No

I agree to electronically sign the Program terms. *

I understand the $125 registration fee per child. *