Massachusetts YMCA Youth & Government

* Registrant:	Delegate: Advisor:
* Delegation:
Branch:
Leadership Role:
* First Name:
* Last Name:
Email:
Birthdate:
School:
Graduation Year:
Gender:
Home Phone:
Cell Phone:
Home Address:
City/State/Zip:

Parent/Guardian:
Parent/Guardian Phone:
Emergency Contact:
Emergency Contact's Phone:

Insurance Carrier:
Policy Number:
Please list any medical conditions, allergies, medications, or food requirements:


Roommate Preferences:
1: 2: 3:

Delegates will be assigned to rooms, with a maximum of 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.