YMCA of Paterson - School Age Program Application
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Child Info
Parent/Guardian
Authorized
Unauthorized
Emergency
Health
Insurance
Consents
Program Selection *
Afterschool Program
Summer Camp
First Name *
Last Name *
Date of Birth *
School *
Gender *
-- Select --
Male
Female
Ethnicity *
-- Select --
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Prefer Not to Say
Grade *
-- Select --
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Contact List
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Phone
Email
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Medical Conditions
Asthma
Seizures
Diabetes
Ear Infections
Allergies Other
Medication Instructions
Insurance Company
Policy Number
I consent to Photo, Video, and Interview
I consent to program evaluation
Submit Application
Detailed Contact Information
Basic Identity
First Name *
Last Name *
Relationship *
-- Select Relationship --
Mother
Father
Step-Parent
Grandparent
Legal Guardian
Sibling
Aunt/Uncle
Cousin
Family Friend
Foster Parent
Caseworker
Other
Email Address
Phone Numbers
Cell Phone *
Home Phone
Address & Location
Street Address *
Apt/Suite (Optional)
ZIP Code *
Employment Information
Employer
Work Phone
Legal / Educational Flags
Restraining Order in place?
IEP / 504 Plan active?