STEM at the Y

STEM at the Y

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

First NameLast Name
Student Date of Birth

MonthDayYear
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Gender

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: