Y Achievers Interest Form

Branch Info

Please select the Greater Philadelphia YMCA branch closest to your home.

Click here for a list of Greater Philadelphia YMCA locations.

Teen Information

First Name

Last Name

Student ID #

Teen Email Address

Teen Phone #

Teen Gender

Teen Age

Teen Grade

T-shirt Size

Date of Birth

Family Information

Guardian #1 Info

Full Name

Email Address

Phone #

Authorized to Pick Up

Address

Guardian #2 Info

Full Name

Email Address

Phone #

Authorized to Pick Up

Address

Emergency Contact

Full Name

Relation to Teen

Email Address

Phone #

Household Info

Please tell us how many of the following live in your household?

Adults (Ages 18-64)

Seniors (Ages 65+)

Infants (Ages 0-2)

Toddlers (Ages 3-4)

Youth (Ages 5-17)

Current total annual income:

Optional and does not determine acceptance into the program.

Health History

List known allergies:

Explain any special accommodations needed:

Does your teen take any medications on a regular basis?

List any medications your teen takes on a regular basis:

Include dosage, time of day, and reason.

Insurance Infomation

Is the teen covered by medical insurance?

Insurance Group #

Insurance ID #

Treatment or Emergency Care

I agree to the following:

I understand that this completed form may be photocopied for trips outside the YMCA facility.Health history is correct and complete as far as I know.The person herein described has permission to engage in activities, except as noted.The person in charge has permission to take my child to the nearest emergency facility for treatment deemed necessary.

Consent and Acknowledgment

Please check all boxes after reading to show you understand:

I acknowledge that staff at the YMCA will maintain First Aid/CPR, AED, and O2 trainings.I understand that staff have first aid supplies that are available if needed.I understand that I am responsible for any emergency transport of my child.I received and will sign and return with this form the liability waiver.

I consent for my teen to:

For my teen to be transported and supervised by staff to and from the program.For my teen to participate in satisfaction and outcome surveys.For my teen to be photographed and/or videotaped while participating in the program.To be added to an email list for notifications about upcoming YMCA programs/events.For my teen to participate in water activities, such as bodies of water provided by YMCA.

Email Function