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Nita M. Lowey 21st Century YMCA Registration Form
Registration YMCA
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Email
*
Your email
Name
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
*
Female
Male
Grade
*
7
8
9
10
11
12
Student ID/Lunch Code
*
Your answer
Ethnicity
*
American Indian/Alaskan Native
Asian
Black (Not of Hispanic Origin)
Native Hawaiian or other Pacific Islander
White (Not of Hispanic Origin)
Two or More races
Other:
Lunch Status
*
Free
Full
Reduced
List any food Allergies
Your answer
Primary Language
*
English
Spanish
Other:
Home Address
*
Your answer
Mailing Address if different than Home Address
*
Your answer
Who do you live with?
*
Both Parents
Single Parent Mother
Single Parent Father
Foster Care
Grandparent (s)
Guardian
Joint Custody
Other:
Transportation Home- Transportation will not be provided so please make arrangements to have you child picked up by 5:30pm
*
Walk
Bus
Pickup
Other:
We are operating Remotely for now. If/when we begin in person tutoring and homework help will you be able transportation home at 3:30. (NO BUS)
Yes
No
Maybe
Clear selection
Pick up Restrictions
*
Your answer
Special Education- Is your child on an IEP or 504 plan?
*
Yes
No
Other:
Does child have special needs or restrictions on activity?
*
Yes
No
If you answered yes to your child having special needs or restrictions on activity? Explain:
Your answer
Do you have internet access?
Yes
No
Maybe
Clear selection
Parents, are you willing to participate in 3 family (Parent & Student) functions throughout the school year?
*
Yes
No
Parents, are you willing to drive to special events to drop your student off? These would be rewards to students and families for participating in the program. Busing is not an option currently. (example: Hockey game @US Bank, Kings Island)
Yes
No
Maybe
Clear selection
Primary Contact: Name of Parent/Legal Guardian and Contact information
*
Your answer
Phone Number
Your answer
Email
Your answer
Secondary Contact: Name of Parent/Legal Guardian and Contact information (Phone, E-mail)
*
Your answer
Third Contact: Name of Parent/Legal Guardian and Contact information (Phone, E-mail)
Your answer
NAME OF PARENT legally authorized to sign for your Participation. (By signing this you are giving permission for us to contact you on behalf of the program and your child to participate in the activities provided. By placing your name below you are authorizing that this will act as your signature and all that applies with a hand written signature.)
*
Your answer
Please let us know any other information you deem necessary or important pertaining to your child. (Allergies)
Your answer
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