Youth Civic Engagement Interest Form
Student Information
Name
Address
Phone
Email
Birthdate
Gender
Please select...
Male
Female
Non-binary
Prefer not to answer
School
Grade
Please select...
6
7
8
9
10
11
12
Which type of career path are you most interested in?
Please select...
Business
Law (Lawyer, Paralegal, Judicial Clerk)
Media (Journalist, Social Media, Reporter)
Lobbyist (Influence public officials to pass laws)
Public Policy (Jobs that focus on finding solutions for public concerns)
Teacher
Marketing (Content Creator, Digital Marketing, Graphic Designer)
Public Relations/Communications
Politician
Campaign Manager (Work with a team to get an individual elected)
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.
Please select...
Ambler YMCA (Ambler, PA)
Boyertown YMCA (Boyertown, PA)
Christian Street YMCA (Philadelphia, PA)
Columbia North YMCA (Philadelphia, PA)
Mt. Laurel YMCA (Mt. Laurel, NJ)
Roxborough YMCA (Philadelphia, PA)
Spring Valley YMCA (Limerick, PA)
West Philadelphia YMCA (Philadelphia, PA)
Click here
for a list of Greater Philadelphia YMCA locations.
Demographic Info
Select the demographic which best describes the participant.
Please select...
African American
Asian
Caucasian
Hispanic/Latino
Multiracial
Other
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
Email
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
No