2024 D90 Power Scholars Academy Registration Form
STUDENT INFORMATION
Student Name
*
Student First Name
Student Last Name
Student Nickname
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Gender
*
Female
Male
Other
Student Race
*
African American/Black
American Indian/AK Native
Asian
Caucasian/White
Hawaiian/Pacific Island
Multiple Races
Student Ethnicity
*
Hispanic/Latino
Non-Hispanic/Latino
2024-2025 Grade
*
1st
2nd
3rd
4th
School
*
Lincoln Elementary
Willard Elementary
T-Shirt Size
*
YXS
YS
YM
YL
YXL
AXS
AS
AM
AL
AXL
I will need extended care from 3pm to 5pm. Please contact me for more details. I understand that this will be an extra cost.
Yes
No
I will need extended care for the following days. Please select all that apply.
*
Monday
Tuesday
Wednesday
Thursday
Friday
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PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 Information
*
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent/Guardian 1 Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian 1 Address
*
Parent/Guardian 1 Street Address
Parent/Guardian 1 Street Address Line 2
Parent/Guardian 1 City
Parent/Guardian 1 State / Province
Parent/Guardian 1 Postal / Zip Code
Parent/Guardian 1 Place of Work
Parent/Guardian 1 Work Address
Parent/Guardian 1 Work Street Address
Parent/Guardian 1 Work Street Address Line 2
Parent/Guardian 1 Work City
Parent/Guardian 1 Work State / Province
Parent/Guardian 1 Work Postal / Zip Code
Parent/Guardian 1 Preferred Phone Number
*
Please enter a valid phone number.
Parent/Guardian 1 Secondary Phone Number
Please enter a valid phone number.
Parent/Guardian 1 Email Address
*
example@example.com
Would you like to add an additional parent/guardian?
*
Yes
No
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Parent/Guardian 2 Information
Parent/Guardian 2 Name
*
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Date of Birth
*
-
Month
-
Day
Year
Date
Does this parent/guardian reside at the same address as parent/guardian 1?
*
Yes
No
Parent/Guardian 2 Address
*
Parent/Guardian 2 Street Address
Parent/Guardian 2 Street Address Line 2
Parent/Guardian 2 City
Parent/Guardian 2 State / Province
Parent/Guardian 2 Postal / Zip Code
Parent/Guardian 2 Place of Work
Parent/Guardian 2 Work Address
Parent/Guardian 2 Work Street Address
Parent/Guardian 2 Work Street Address Line 2
Parent/Guardian 2 Work City
Parent/Guardian 2 Work State / Province
Parent/Guardian 2 Work Postal / Zip Code
Parent/Guardian 2 Preferred Phone Number
*
Please enter a valid phone number.
Parent/Guardian 2 Secondary Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Email Address
example@example.com
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Emergency Contact Information
Emergency Contact will be called in the case we are not able to get a hold of guardians/parents. Emergency Contacts will also be allowed to pick up your child. For the safety of your child, everyone picking up your child must have a picture I.D. Anyone without proper authorization will not be allowed to take your child.
Emergency Contact Name 1
*
Emergency Contact 1 First Name
Emergency Contact 1 Last Name
Emergency Contact 1 Relationship to Child
*
Grandmother
Grandfather
Sibling (must be 18 or older)
Aunt
Uncle
Family Friend
Other
Emergency Contact 1 Address
*
Emergency Contact 1 Street Address
Emergency Contact 1 Street Address Line 2
Emergency Contact 1 City
Emergency Contact 1 State / Province
Emergency Contact 1 Postal / Zip Code
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Would you like to add another Emergency Contact?
*
Yes
No
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Emergency Contact 2
*
Emergency Contact 2 First Name
Emergency Contact 2 Last Name
Emergency Contact 2 Relationship to Child
*
Grandmother
Grandfather
Sibling (must be 18 or older)
Aunt
Uncle
Family Friend
Other
Emergency Contact 2 Address
*
Emergency Contact 2 Street Address
Emergency Contact 2 Street Address Line 2
Emergency Contact 2 City
Emergency Contact 2 State / Province
Emergency Contact 2 Postal / Zip Code
Emergency Contact 2 Phone Number
*
Please enter a valid phone number.
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Additional Authorized Pick-Up
All individuals who wish to pick up your child must be listed below, excluding parents, guardians, and emergency contacts listed under general information. If anyone other than those listed will be picking up your child, you must contact Youth Development Program Staff via powerscholars@westcookymca.org. Phone authorization will not be sufficient. For the safety of your child, anyone picking up your child must have a picture ID. Anyone without proper authorization will not be allowed to take your child.
Do you wish to authorize additional individuals to pick up your child?
*
Yes
No
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Additional Pick Up 1 Name
*
Additional Pick Up 1 First Name
Additional Pick Up 1 Last Name
Additional Pick Up 1 Phone Number
*
Please enter a valid phone number.
Additional Pick Up 1 Relationship to Child
*
Grandmother
Grandfather
Sibling (must be 18 or older)
Aunt
Uncle
Family Friend
Other
Conditions for releasing child (if any) for Additional Pick Up 1
*
Would you like to authorize additional individuals to pick-up your child?
*
Yes
No
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Additional Pick Up 2 Name
*
Additional Pick Up 2 First Name
Additional Pick Up 2 Last Name
Additional Pick UP 2 Phone Number
*
Please enter a valid phone number.
Additional Pick Up 2 Relationship to Child
*
Grandmother
Grandfather
Sibling (must be 18 or older)
Aunt
Uncle
Family Friend
Other
Conditions for releasing child (if any) for Additional Pick Up 2
*
Would you like to authorize additional individuals to pick-up your child?
*
Yes
No
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Additional Pick Up 3 Name
*
Additional Pick Up 3 First Name
Additional Pick Up 3 Last Name
Additional Pick Up 3 Phone Number
*
Please enter a valid phone number.
Additional Pick Up 3 Relationship to Child
*
Grandmother
Grandfather
Sibling (must be 18 or older)
Aunt
Uncle
Family Friend
Other
Conditions for releasing child (if any) for Additional Pick Up 3
*
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Permissions and Authorizations
Photo/Video Permission Authorization
*
I give permission for my child to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be used for West Cook YMCA marketing and communications including but not limited to using within the facility, newspapers, or other media outlets
I DO NOT give permission for my child to have their picture and/or video taken for the purpose of West Cook YMCA marketing and communications including but not limited to using within the facility, newspapers, or other media outlets
Hold Harmless Indemnification Authorization
*
I agree that the West Cook YMCA shall not be responsible for any personal injuries or losses sustained by me/my child while on any YMCA premises or as a result of YMCA sponsored activities. I further agree to idemnify and hold harmless the West Cook YMCA from any claims or demands arising out of any such injuries or losses. If I am asked, I also agree to leave the facility due to inappropriate behavior as defined by the YMCA staff. A refund will not be given if asked to leave.
Medical Permission Authorization
*
I agree to give permission for my child's medical information to be released to West Cook YMCA.
I do not give permission for my child's medical information to be released to West Cook YMCA.
I give authorization based on the above marked boxes.
Date of Signature
-
Month
-
Day
Year
Date
Submit
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