YMCA Youth Leadership Chattanooga - Student Application 2025-2026

Youth Leadership Chattanooga

Student Application 2025-2026 School Year
Deadline to apply is September 12, 2025

10th and 11th grade students should be completing this application themselves, while with a parent/caregiver as their information and signature will be required at the end of the application.
Student Name*

First NameLast Name
Student Date of birth*

MonthDayYear
Date
Student Cell phone number *
Please enter a valid phone number.
Your home/mailing address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student email address (NOT a school email address - external program partners cannot email these addresses):*
example@example.com; if you don't have an email address that is NOT a school address, use your parent/caregiver email here
Ethnicity:*
Gender:*
Race:*
Grade for 2025-2026 school year:*
School for the 2025-2026 year:*
School address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tell us about yourself!
Describe yourself using a few phrases or adjectives:*
Tell us about two areas that concern you most about life in Chattanooga (1):*
Tell us about two areas that concern you most about life in Chattanooga (2):*
What would you like to gain from a program like Youth Leadership Chattanooga?*
What are your college or career objectives? What jobs interest you? Are you planning to go to college? (300-500 words)*
Schedule of Events

A total of nine (9) sessions are held for Youth Leadership Chattanooga. Participants are expected to attend all nine sessions. Extenuating circumstances which require you to miss all or part of a session may be submitted to the Program Coordinator for consideration. Please note the following: Students will not be allowed to leave during a program session without the written permission of a parent/caregiver and transportation to/from the drop off location for YLC program days are the responsibility of the student.
All programs are scheduled for Wednesdays. School absence notes can be provided, by request.

Program Dates (all program days are 8am to 3pm unless otherwise noted):
- September 24, 2025 (8am until evening)- Camp Ocoee Kick-Off Retreat
- October 8, 2025
- November 12, 2025
- December 10, 2025
- January 14, 2026
- February 11, 2026
- March 11, 2026
- April 15, 2026
- May 13, 2026 - YLC Graduation event (evening)
After reviewing the schedule of events (below), do you see any conflicts with attending any scheduled sessions?*

YesNo
Signature of applicant:

Clear
Parental/Caregiver Permission

This part needs to be filled out and signed by your responsible adult party!
I am the parent or legal guardian of the student named above. I have read the information on Youth Leadership Chattanooga and I am willing to have my student participate if selected. Youth Leadership Chattanooga and all their agenda and employees have my full permission and consent to transport or provide other transportation for my child by public bus service, van, or other appropriate transportation in connection with all sessions of Youth Leadership Chattanooga during the school year in which my student is a participant. I hereby release and hold harmless Youth Leadership Chattanooga and the YMCA of Metropolitan Chattanooga, their members, agents, employees, or any individual involved in planning, organization, or presentation of Youth Leadership Chattanooga programming for any accident, injury, illness, or damage whatsoever related to the above-mentioned student's attendance or participation in any activity or session of Youth Leadership Chattanooga.
Parent/Caregiver Full Name*

First NameLast Name
Parent/Caregiver Signature*

Clear
Parent/Caregiver address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/caregiver email address:*
We must have at least one parent/caregiver email address to keep you updated on upcoming programs days and any changes needed in the schedule.
Emergency Contact and Health Information
Emergency Contact #1*

First NameLast Name
Relationship to student?*
Cell phone of emergency contact #1*
Please enter a valid phone number.
Emergency contact #2*

First NameLast Name
Relationship to student for contact #2*
Cell phone of emergency contact #2*
Please enter a valid phone number.
Is there any reason to restrict the student from any activities?*

NoYes
If yes, please explain:
Does the student have any health concerns or need special accomodations?*

NoYes
If yes, please explain:
Please list all known allergies (food, medication, other) and any dietary restrictions. If none, please enter "none".*
Does the student take any medication on a regular basis, either prescribed or over-the-counter?*

NoYes
If yes, please explain:
While Youth Leadership Chattanooga will make every attempt to provide reasonable accommodations for mentally and physically challenged children, Youth Leadership Chattanooga will not accept children that are (1) of danger to themselves, (2) of danger to others, or (3) a disruption to the normal activities making it unreasonably difficult for other children to enjoy programs. Any of the above reasons will be grounds for dismissal from Youth Leadership Chattanooga. A parent/guardian must discuss with the Program Director any special conditions or circumstances involving their child. This must be completed prior to registration so that we can advise you as to whether we can make a reasonable accommodation for your child.

I approve this registration and certify that the student is capable of an overnight camp experience. I grant permission for the student to participate in all planned activities including out-of-camp trips by van or bus, hiking and/or boating. In case of an accident or illness, the YMCA is authorized to secure emergency medical treatment. Prudent attempts will be made to contact the student’s caregiver immediately. I hereby give my permission to the medical personnel selected by the Program Director to order X-rays, routine tests and treatment, and to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. I understand that the YMCA assumes no responsibility for injuries or illnesses which my child may sustain as a result of his/her physical condition or resulting from his/her participation in these activities. I hereby voluntarily release and discharge YMCA Camp Ocoee/YMCA of Metropolitan Chattanooga/Youth Leadership Chattanooga, it’s agents, contract services, and employees from any and all claims for injury, illness, death, loss or damage which my child may suffer as a result of his/her participation in these activities. I understand that no medical insurance is provided by the YMCA. The YMCA is not responsible for lost, stolen or damaged personal articles. I also authorize the YMCA to have and use photographs and/or videos of the camper named on this registration as may be needed for promotional purposes.
Should be Empty:

Youth Leadership Chattanooga

Tell us about yourself!

Schedule of Events

Parental/Caregiver Permission

Emergency Contact and Health Information