The Saturday Club Application - YMCA of the Roses

Saturday Robotics Club Registration

Student's First Name

Student's Last Name

DOB

Age

Ethnicity

Gender

Male

Female

Address

City

State

Zip

School

Grade

Teacher's Name (Homeroom, Adviser, etc.)

List Any Allergies:

Parent1/Guardian1 First Name

Parent1/Guardian1 Last Name

Parent1 Phone Number

Parent1 Email Address

Parent2/Guardian2 First Name

Parent2/Guardian2 Last Name

Parent2 Phone Number

Parent2 Email Address

I authorize the release of my child’s picture to be used on Young Thinkers of York’s website, any marketing material (such as our team brochure), and social media platforms (Facebook, Twitter, etc). This includes individual and group photos and videos. Only the student’s first name will be published.

No Yes

To help the YMCA better understand who they serve and receive funding to keep our robotics programs free for families, please answer the following 2 questions:

Total Household Income

Number of Dependents