2026-2027 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

Other
Student Grade
School Name
Student Ethnic Origin
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
Which Summit Area YMCA location will you call 'home'?
I would like to be added to Remind for text reminders regarding meetings, events, cancellations, and reminders
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

Other
What are your plans after graduating high school?

Other
What types of workshops would interest you?

Other
Code of Conduct Agreement
Waiver & Release of Liability
Please confirm you are not a robot
Student Signature
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Summit AREA YMCA Achievers Application