Youth and Government Club Interest Form
Contact Information
First Name
Last Name
Contact Email
Contact Number
I am a ...
Teen
Parent
Educator/School Administrator
Grade
6th
7th
8th
9th
10th
11th
12th
What program your interested in?
Middle School (6th-8th)
High School (9th - 12th)
School Information
Full School Name
Please include the full name for your school, not an abbreviated version. For example, if you go to Austin High School, you would write Stephen F. Austin High School.
School City
School/District Website
Region
District Director
District
YMCA
School Address
City
State
Zip Code
Do you have a Club Sponsor/Advisor?
Yes
No
Sponsor/Advisor Name
Sponsor/Advisor Email
How did you hear about us?
YMCA Branch
School Staff Member
Student/Peer
Social Media
Website
Other
Please explain if other:
Student Name
Staff Name
Contact Information