YLA Student's Information

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Youth's Information

Please submit this form once for each of your children that you would like to sign up for Youth Leadership Academy.

This information will be provided to the Y staff who are supervising your child at the school or at the Y.

This form does not guarantee your child's spot in YLA. (Your child's spot is reserved for each day that is paid for in advance.)

Youth's Information

Youth's Information
Name Age Date of Birth Entering Grade School

Promotional Agreement

Yes

The Two Rivers YMCA and its funding partners have my permission to use photographs or videos of my child in YMCA promotional materials.

Internet Usage

Yes

I give permission for my child to use the internet under the supervision of the Y staff.

Accommodations

Please list any special needs (health, physical, dietary, educational, behavioral, etc)

Allergies

Please list any allergies.

Medications

Please list all current prescription medications.

Limited or Encouraged Activities

Please describe any specific activited to be encouraged or limited by physician's advice.