United Way of Central Massachusetts | YouthConnect Worcester Registration Page

Gender of Participant: *

Male
Female
Non-Binary
Self-Describe/Other

Are You Interested In Attending Gender Specific Programming on Fridays? *

Yes
No

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Which Program Format Will You Be Accessing? *

In Person
Virtual
Both

Participant First Name: *

Participant Middle Name:

Participant Last Name: *

Nickname:

Parent/Guardian Name: *

Week 1: July 6th to July 9th (Only 1 Selection Per Week) *

Week 1 registrations MUST be submitted no later than June 29th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021..

Week 1: July 6th to July 9th (Only 1 Selection Per Week) *

Week 1 registrations MUST be submitted no later than June 29th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021..

Will The Participant Be Attending Gender Specific Programming (7/9)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/9)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/9)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 2: July 12th to July 16th (Only 1 Selection Per Week) *

Week 2 registrations MUST be submitted no later than July 5th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 2: July 12th to July 16th (Only 1 Selection Per Week) *

Week 2 registrations MUST be submitted no later than July 5th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (7/16)? *

Camp Kinneywood (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/16)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/16)? *

Camp Kinneywood (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 3: July 19th to July 23rd (Only 1 Selection Per Week) *

Week 3 registrations MUST be submitted no later than July 12th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 3: July 19th to July 23rd (Only 1 Selection Per Week) *

Week 3 registrations MUST be submitted no later than July 12th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (7/23)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/23)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/23)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 4: July 26th to July 30th (Only 1 Selection Per Week) *

Week 4 registrations MUST be submitted no later than July 19th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 4: July 26th to July 30th (Only 1 Selection Per Week) *

Week 4 registrations MUST be submitted no later than July 19th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (7/30)? *

Camp Kinneywood (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/30)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (7/30)? *

Camp Kinneywood (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 5: August 2nd to August 6th (Only 1 Selection Per Week) *

Week 5 registrations MUST be submitted no later than July 26th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 5: August 2nd to August 6th (Only 1 Selection Per Week) *

Week 5 registrations MUST be submitted no later than July 26th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (8/6)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/6)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/6)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 6: August 9th to August 13th (Only 1 Selection Per Week) *

Week 6 registrations MUST be submitted no later than August 2nd, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 6: August 9th to August 13th (Only 1 Selection Per Week) *

Week 6 registrations MUST be submitted no later than August 2nd, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (8/13)? *

Camp Kinneywood (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/13)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/13)? *

Camp Kinneywood (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 7: August 16th to August 20th (Only 1 Selection Per Week) *

Week 7 registrations MUST be submitted no later than August 9th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 7: August 16th to August 20th (Only 1 Selection Per Week) *

Week 7 registrations MUST be submitted no later than August 9th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (8/20)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/20)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/20)? *

Camp Wind-In-The-Pines (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Week 8: August 23rd to August 27th (Only 1 Selection Per Week) *

Week 8 registrations MUST be submitted no later than August 16th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Week 8: August 23rd to August 27th (Only 1 Selection Per Week) *

Week 8 registrations MUST be submitted no later than August 16th, 2021. There is a limited capacity per site, so please only register for the weeks that your child will attend Summer YouthConnect 2021.

Will The Participant Be Attending Gender Specific Programming (8/27)? *

Camp Kinneywood (GIRLS ONLY)
BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/27)? *

BGCW & ME4 @ GBV (BOYS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Will The Participant Be Attending Gender Specific Programming (8/27)? *

Camp Kinneywood (GIRLS ONLY)
Not Attending

Gender Specific Programming includes Girls Night at Camp: Fridays ONLY, 6-9 PM. and Boys Night at ME4: Fridays ONLY, 5:30-9 PM.

Street Address: *

Address Line 2:

City: *

Zip/ Postal Code: *

State: *

Cell Phone Number: *

Home Phone Number:

Email: *

Date of Birth: *//

Age *

Grade Entering *

School Attending During The 2020-2021 School Year: *

Please Type Out The School Name: *

Primary Language(s) Spoken At Home (Check All That Apply):

Please Write In The Other Language(s) Spoken At Home:

Race (Check All That Apply):

Ethnicity (Check All That Apply):

Emergency Contact Name: *

Must be different than primary parent/guardian.

Emergency Contact Phone Number: *

Does Participant Have Any Allergies/Sensitivities?: *

Please List The Allergies/Sensitivities: *

Such as peanut allergies, bee stings, etc.

Does Participant Have Any Health Problems?: *

Please List Them: *

Such as asthma, diabetes, kidney problems, seizure disorder, heart condition, etc.

Has Participant Suffered Any Head Injuries In The Past 12 Months?: *

Yes
No

Does Participant Take Any Medication?: *

Please List The Medication: *

Such as an Epipen, Insulin, etc.

Primary Care Physician: *

Physician's Phone Number: *

With Whom Does The Participant Live?:

Parent/Guardian Marital Status:

Number Of People In Your Household (Including Adults): *

Annual Household Income: *

Please combine income of ALL household occupants.

Has Child Ever Participated In A YouthConnect Summer Program Before?: *

Yes
No

How Did You Hear About YouthConnect Worcester?:

Has Child Ever Attended Any YouthConnect Partner Agency's After-School Program?: *

Yes
No

On An Average Night, How Will The Participant Get To Their Program Site? (Check All That Apply): *

Walk
Drop-Off
Neighborhood Bus

What Is Your Primary Bus Stop?: *

All pick-up spots will drop off at each program site.

Would You Like An Alternative Bus Stop? *

Yes
No

In cases of shared custody, guardianship, location change

What Is Your Alternate Bus Stop?: *

All pick-up spots will drop off at each program site.

Reason For Alternate Bus Stop: *

I Give My Child Permission To Participate In Strenuous Activities And High-Risk Activities That May Include But Are Not Limited to Kick Boxing, Swimming, Dance, Rock Climbing, And Etc. *

Yes
No

I Give Permission For Sunscreen To Be Administered To My Child: *

Yes
No

I Give Permission For Bug Spray To Be Administered To My Child: *

Yes
No

I Give Permission For My Child's Photograph To Be Taken For Use By YouthConnect Worcester In Program Brochures, Annual Report, Website, Social Media, Other Promotional Materials, And For Release To Local Newspapers: *

Yes
No

I Give Permission For My Child To Complete Surveys And Assessment Tools As Part Of The Program. The Survey Results Are Confidential: *

Yes
No

I Give YouthConnect Permission To Transport My Child To And From YouthConnect And Offsite Activities And Events: *

Yes
No

I Give My Child Permission To Participate In YouthConnect Programs And Activities. I Understand That My Child Must Abide By YouthConnect Rules, Regulations, COVID Guidelines, And Cooperate With All Staff And Personnel. I Understand That His Or Her Failure To Do So May Result In My Child’s Suspension From The YouthConnect Program. In The Event That I Cannot Be Reached In An Emergency, I Hereby Give Permission For My Physician Or An Emergency Physician To Secure And Administer Treatment, Including Hospitalization For My Child Named Above: *

Yes
No

I Acknowledge That YouthConnect Worcester Is Following Sanitization And Safety Guidelines Provided By The Massachusetts Department Of Public Health, Which May Include Health Screenings, Temperature Checks, And Intensified Cleaning, Sanitizing, And Disinfecting Practices. * Protocols May Vary By Site. *