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Student Information

Family Information

Father/Guardian Information
Father/Guardian Address
Mother/Guardian Information
Mother/Guardian Home Address
Authorizations and Waivers
Please check to indicate agreement of each statement
I hereby authorize and grant permission to the YMCA to transport my child by a YMCA vehicle and/or hired transportation company for sessions, activities or field trips held outside of Transylvania University.
The Teen Achiever will receive a complimentary YMCA of Central Kentucky teen membership as long as he/she is enrolled in the program. Membership will be termed at the end of the program or if dismissed from program. If student wishes to keep membership after program concludes, a Change of Information form must be submitted at the end of the program.
I give the YMCA permission to use my child’s photo or video footage in promotional materials.
I give the YMCA permission to track my child's academic status in high school and college using a qualifable third party tracking company. YMCA staff have my permission to collect grades, test scores and any other information that will assist my child in reaching their academic and career goals. 
I understand that I will not receive a refund for program fees paid for my child. 
We understand some sessions will conduct age-appropriate workshops to our participants that may involve discussion of sensitive subject matters such as but not limited to child abuse prevention and awareness, drug and alcohol awareness, bullying, vehicle safety, proper hygiene, social media and inappropriate content and other topics to be determined as essential to life skills for youth.
In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to order injection, anesthesia or surgery for my child as named above, in the event of a life or death emergency. I understand the YMCA of Central Kentucky carries liability insurance only and will not be responsible for injuries and accidents while participating in YMCA programs or facilities. Families must carry their own accident insurance.
YMCA programs and services are available to everyone – regardless of age, background, ability or income through the YMCA financial assistance program. We award financial assistance for membership and programs and applications are available at any YMCA of Central Kentucky location or at ymcacky.org. Applications are renewed annually with full documentation and full payment is required until application is approved. Please allow two weeks for processing.
I have read, understand and agree to comply with the policies and code of conduct of the YMCA of Central Kentucky Black Achievers program. I understand the YMCA staff may require parent conferences to address any problematic behaviors. YMCA staff reserve the right to suspend or discontinue services at any time based on the severity of the incident, even if it is the child’s first infraction. To the best of my knowledge, the information on the registration form is complete and accurate.
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