2025-2026 Achievers Application

Summit AREA YMCA Achievers Application

The program application must be completed by a parent/guardian and student.
STUDENT INFORMATION
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Student Email*
example@example.com
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Gender*

FemaleMaleOther
Student Grade*

9101112
School Name*
Student Ethnic Origin*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteTwo or More RacesPrefer not to say
Please note: Y-USA requests the above information from YMCA participants throughout the nation for program funding and demographic purposes.
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Relationship to Student*
Parent/Guardian Date of Birth*

MonthDayYear
Parent/Guardian Phone Number*
Parent/Guardian Email*
example@example.com
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Do you want to provide Emergency Contact information for the student that is different from the Parent/Guardian information provided above?*
Name

First NameLast Name
Relationship to Student
Phone Number
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Summit Area YMCA location will you call 'home'?*

Summit YMCABerkeley Heights YMCA
I would like to be added to Remind for text reminders regarding meetings, events, cancellations, and reminders

YesNo
STUDENT PROFILE
Why do you want to become a member of the Y Achievers program?*
What school or out of school clubs/activities do you participate in? Please include days/times.*
Goals
What Career fields are you interested in? You may choose more than one

ArtEngineeringCommunicationsBusiness/FinanceYouth workLaw/GovernmentHealth/Medical EducationOther
What are your plans after graduating high school?

4-year college/universityCommunity CollegeTech/Trade SchoolMilitary ServiceOther
What types of workshops would interest you?

Financial aid/ScholarshipsCareer OpportunitiesCollege AdmissionsPersonal FinancesCollege LifeOther
Code of Conduct Agreement*
Waiver & Release of Liability*
Please confirm you are not a robot*
Student Signature

Clear
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Summit AREA YMCA Achievers Application