WAITLIST - 2026 Student Registration

The Prom Registration is currently full. Please complete this form to be added to the waitlist.
Student WAITLIST Registration: Summit Area YMCA & Summit Elks Lodge 1246

Thursday, May 14, 2026 at the Berkeley Heights YMCA
Student Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
MaleFemaleOther
Parent/Guardian Emergency Contact Name*

First NameLast Name
Parent/Guardian Emergency Contact Phone Number*
Format: 000-000-0000.
Parent/Guardian Emergency Contact Email*
example@example.com
Parent/Guardian Relationship to Child*
Please note: Y-USA requests the following information from YMCA participants throughout the nation for demographic and grant funding purposes.
WhiteBlack/African-AmericanNative Hawaiian/Pacific IslanderAsianAmerican Indian/Alaska NativeTwo or More RacesPrefer not to say
- Please share special concerns we should be sensitive to (ex. sensory issues and/or sensitivities to light, sound, smell, touch, etc.)?*
- YesNo
- YesNo
- Caregiver Name (if applicable)
  
  First NameLast Name
- If you would like your child to be seated with another guest, please share their name:
- YesNo
- Please list any special dietary or allergy issues?*
- Any other concerns regarding your child that we should be made aware of?*
- In an effort to keep our members and facilities safe, and in order to use Summit Area YMCA facilities, all members and guests 18+ years and a parent/guardian for minor participants under the age of 18 are required to agree and sign our Waiver and Release of Liability & Code of Conduct.
- Signature*
  
  Clear
- Please verify that you are human*
- Should be Empty:

The Prom Registration is currently full. Please complete this form to be added to the waitlist.

Student WAITLIST Registration: Summit Area YMCA & Summit Elks Lodge 1246