Registration Page
YMCA Achievers 2018-2019

Welcome to the Achievers program. It is our delight to welcome you to this new semester. We have a very exciting year planned for you. Please fill out this simple form to register and we will reach out to you as soon as we review your application. There is a $20 registration fee for every new and returning applicant this year. Please bring it to the kickoff at the registration desk. Hope to see you there.

Students Name

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* 1. Students Name

Students Last Name

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* 2. Students Last Name

Students Middle Name

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* 3. Students Middle Name

School

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* 4. School

Grade

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* 5. Grade

Student Date of Birth

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* 6. Student Date of Birth

Date 
Student Gender

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* 7. Student Gender

Students Race 

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* 8. Students Race 

Student Phone Number

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* 9. Student Phone Number

Student Email Address

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* 10. Student Email Address

What is your current GPA? 

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* 11. What is your current GPA? 

Parent/Tutor Name

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* 13. Parent/Tutor Name

Parent/Tutor Last Name

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* 14. Parent/Tutor Last Name

Relationship with the student

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* 15. Relationship with the student

Family Home Address - Street

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* 16. Family Home Address - Street

City

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* 17. City

State

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* 18. State

Zip

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* 19. Zip

Parent Email Address

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* 20. Parent Email Address

Home Phone

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* 21. Home Phone

Cellphone

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* 22. Cellphone

Family Income Level

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* 23. Family Income Level

Is your son/daughter a first generation student (A first-generation college student is defined as a student whose parent(s)/legal guardian(s) have not completed a bachelor’s degree at a four-year college or university)

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* 24. Is your son/daughter a first generation student (A first-generation college student is defined as a student whose parent(s)/legal guardian(s) have not completed a bachelor’s degree at a four-year college or university)

Is your son/daughter eligible to receive reduced lunch?

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* 25. Is your son/daughter eligible to receive reduced lunch?

Emergency Contact Full Name 

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* 26. Emergency Contact Full Name 

Emergency Contact Phone Number

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* 27. Emergency Contact Phone Number

Please describe any medical condition or concerns

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* 28. Please describe any medical condition or concerns

Please describe any allergies

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* 29. Please describe any allergies

If you have any further question please feel free to contact adutta@cincinnatiymca.org

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