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MA YMCA Youth & Government » Online Registration for Pre-Leg 3

* 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.

 





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