YMCA Safety Around Water Application Form

Thank you for your interest in the Y Safety Around Water program. If you are new to the Y, please create a new account. Otherwise, complete the information below for all participants. Note: Do not create a new account if you’ve used Y programming in the past. Call us at 612-230-9622, if you are unsure.

* All fields required unless otherwise noted

Enter Parent Information

First Name

Last Name

Address

Address 1

Address 2 (optional)

City (optional)

State (optional) - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)CaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMicronesiaMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip code

Phone Number

Email Address

Parent Date of Birth

Date

Preferred Y Location Select one...AndoverBlaisdellBurnsvilleDayton at GaviidaeEaganElk RiverEmma B. Howe - Coon RapidsForest LakeHarold Mezile North Community YMCA Youth & Teen Enrichment CenterHastingsHudsonMaplewood YMCA Community CenterNew HopeRidgedale - MinnetonkaShoreviewSouthdaleSt. Paul EastsideSt. Paul MidwayWhite Bear AreaWoodbury

Is your child on a free reduced school lunch?

Yes

No

How many people live in your household?

2

3

4

5

6 or more

What is your household income?

<$10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

>$40,000

Enter Participant Information

Participant 1 First Name

Participant 1 Last Name

Participant 1 Date of Birth

Date

Participant 1 Gender

Male

Female

Participant 1 Ethnicity

African American or Black

Hispanic or Latino

White

Asian or Pacific Islander

American Indian or Alaska Native

Middle Eastern

Two or more races

Add up to 3 additional optional participants below. If you need to add more than 3, please submit the form again with the additional participant information.

Participant 2 First Name

Participant 2 Last Name

Participant 2 Date of Birth

Date

Participant 2 Gender

N/A

Male

Female

Participant 2 Ethnicity

N/A

African American or Black

Hispanic or Latino

White

Asian or Pacific Islander

American Indian or Alaska Native

Middle Eastern

Two or more races

Participant 3 First Name

Participant 3 Last Name

Participant 3 Date of Birth

Date

Participant 3 Gender

N/A

Male

Female

Participant 3 Ethnicity

N/A

African American or Black

Hispanic or Latino

White

Asian or Pacific Islander

American Indian or Alaska Native

Middle Eastern

Two or more races

Participant 4 First Name

Participant 4 Last Name

Participant 4 Date of Birth

Date

Participant 4 Gender

N/A

Male

Female

Participant 4 Ethnicity

N/A

African American or Black

Hispanic or Latino

White

Asian or Pacific Islander

American Indian or Alaska Native

Middle Eastern

Two or more races