YMCA Of Paterson
Admin Login
Youth & Government (YAG) Registration
Program Information
Program Year
Student Information
Full Name
Date of Birth
Age
Grade
Gender
Select...
Male
Female
Ethnicity
Select...
Asian
Black or African American
Hispanic / Latino
Middle Eastern or Northern African
Native American or Alaskan Native
Native Hawaiian or Other Pacific Islander
Other
Two or More Races / Ethnicities
White
School
Street Address
Address Line 2 (Apt, Suite, etc.)
Zip Code
City
State
Student Cell Phone
Student Email
Parent / Guardian Information
Name
Relationship
Select...
Mother
Father
Guardian
Email
Home Phone
Cell Phone
Emergency Contact (someone other than above listed person prefered)
Same as Parent/Guardian
Name
Phone
Relationship
Select...
Mother
Father
Guardian
Aunt / Uncle
Sibling
Other
Please specify relationship
Medical Information
Allergies?
Yes
No
List Allergies
Medications?
Yes
No
List Medications
Doctor's Name
Consents & Agreements
(1) If my child requires emergency medical care and I cannot be reached, I hereby give permission to the YMCA of Paterson to secure the services of a licensed physician.
Yes
No
(2) I agree to pay all of the costs and fees for any emergency medical care for my child.
Yes
No
(3) I hereby give permission for my child to participate in all YMCA Youth & Government activities.
Yes
No
(4) I release the YMCA of Paterson from any and all liability for injuries which may occur while my child is participating in the program.
Yes
No
(5) I give permission for the YMCA of Paterson to photograph or video my child for promotional and marketing purposes.
Yes
No
Parent Signature
Clear
Student Signature
Clear
Submit Registration