Civic Engagement Interest Form

Student Information

Name

Address

Phone

Birthdate

Gender

School

Grade

List any disabilities, allergies, or dietary restrictions we should be aware of.

Parent Information

Parent Name

Parent Address

Parent Email

Parent Phone

YMCA Location

Select the Y location where you would like to participate at.

Click here for a list of Greater Philadelphia YMCA locations.

Program

Which Civic Engagement program are you interested in?

Model United Nations (MUN)

Youth and Government (YAG)

Demographic Info

Select the demographic which best describes the participant.

Emergency Contact

The Greater Philadelphia YMCA Civic Engagement staff will make every effort to contact the parent listed below in the event of an emergency involving your child. The person listed below will be contact if the parent is unavailable.

Name

Phone

Relation to student

Photo Release

I consent to the taking and use of still photography and/or motion pictures of me or my family for use of magazines, television, newspapers, etc. and to the noncommercial use of such photographs or motion pictures promoting the YMCA and YMCA Programs. I understand that the Greater Philadelphia YMCA has no control over and is not responsible for the content in such publication and broadcasts. I hereby and forever waive payment or royalties for the exhibition or showing of photographs or motion pictures and/or the use of information provided by me. The YMCA will post signs/notify me if I am in the building when professional photographers or TV crews are on site so members have the option to avoid their images being utilized.

I consent to the YMCA photo release.

Yes