Massachusetts YMCA Youth & Government

* Registrant:	Delegate: Advisor:
* First Name:
* Last Name:
* Email:
* Delegation:
* Gender:
Cell Phone:

Age:
Emergency Contact:
Phone:

Please list any medical conditions, allergies, medications, or food requirements:


Roommate Preferences:
1: 2: 3:

Delegates will be assigned four to a room, according to gender. Every effort will be made to accommodate roommate preferences; but no guarantee is made. All rooms are NON SMOKING.