Teen Ambassadors

Teen Ambassadors

The program application must be completed by a student and parent/guardian.
The Teen Ambassador Program builds the next generation of leaders by giving teens a voice, responsibility, and real-world leadership experience—preparing them for college, careers, and lifelong community impact
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
FemaleMaleOther
School Name*
Grade*
Why do you want to be a Teen Ambassador?*
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*
Format: 000-000-0000.
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
Format: 000-000-0000.
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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: