Register for P.E.A.R.L.

Join the P.E.A.R.L. Program

To join the PEARL program, make sure to get all of these forms in! Parents or guardians need to submit the first batch, and then participants can take care of all the forms below “Code of Conduct”. We can’t wait to have you on board!

Participant Registration Information

Participants Name

First Name

Last Name

Social Security Number

Date of Birth

MM

DD

YYYY

Grade

School

Parent 1 or Guardian

First Name

Last Name

Parent 2 or Guardian 2

First Name

Last Name

Parent's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell

Parent/Guardian 1 Cell #

Cell #2

Parent/Guardian 2 Cell #

Email

Best way to contact me

Home Phone

Cell Phone

Work Phone

Does your child have any medical conditions?

No

Yes

As it relates to physical activities, does your child have any limited physical activity?

No physical limitations

Yes, my child has physical limitations

My child is allergic to the following (Please list all allergies or note none)

Does Parent/Guardian 2 have the same address?

Yes

No

EMERGENCY MEDICAL RELEASE FORM:

Emergency Medical

Participant Name

First Name

Last Name

In case of an emergency, please notify me first. If I am unable to be reached, please call the following persons:

Emergency Contact #1

First Name

Last Name

Relationship to Participant

Phone

(###)

###

####

Address

Emergency Contact #2

First Name

Last Name

Relationship to Participant

Phone

(###)

###

####

Address

Dr.s Name

First Name

Last Name

Dr.s Phone

(###)

###

####

Dr.s Office Name & Address

I agree to inform the YWCA of Yonkers of any changes in the information provided above and agree that the YWCA of Yonkers will not be liable for any injury arising from my failure to provide such information.

I hereby give any medical facility in Yonkers permission to provide medical emergency services by qualified personnel to my child as may be required in an emergency.

I accept full responsibility for (Participant) en route to and from the YWCA of Yonkers. I hereby give the YWCA of Yonkers permission to administer minor first aid to my child and to take the necessary procedures to provide emergency treatment if the need arises.

Parent/Guardian Electronic Signature

First Name

Last Name

Date

MM

DD

YYYY

GENERAL RELEASE FORM:

General Release Form

By enrolling my child in the YWCA Yonkers, P.E.A.R.L. Program, I hereby authorize my child (named below) to participate in all program activities except as I might otherwise advise in writing. Except as may be due to staff negligence, I therefore release the YWCA Yonkers and its staff, volunteers, or any other person associated with the program from any and all liability for damages and injuries that may occur to my child.

Childs Name

First Name

Last Name

I Agree

Yes

No

CONFIDENTIAL INFORMATION RELEASE:

Confidential Information

I hereby grant permission to duly authorized personnel of the YWCA Yonkers P.E.A.R.L. Program to obtain testing and academic information (including any Individualized Education Program or Resource reports/information) from Yonkers Public Schools relating to my child/ward, for the purpose of providing additional educational support services, homework assistance, or other program related purposes.

Childs Name

First Name

Last Name

I Agree

Yes

FIELD TRIPS:

Offsite Release

I give my child permission to take part in FIELD TRIPS with the YWCA Yonkers as a participant of the P.E.A.R.L. Program and thus release the YWCA Yonkers from the responsibility for any accidents that may occur not due to staff negligence.

I Agree

Yes

No

Childs Name

First Name

Last Name

Photo Release for Press/Socials/Marketing:

Photo Release

In connection with programs and activities of the YWCA of Yonkeers I give the YWCA of Yonkers permission to take pictures of my child, and release such pictures for marketing purposes. This includes pictures and articles released on the YWCA of Yonkers website, the press and, social media platforms.

I Give Permission

Yes

No

Childs Name

First Name

Last Name

For participants under 14 it is necessary to clarify how you would like the participant to leave the YWCA Yonkers premises.

If the participant is over 14 years of age you may skip to the next electronic permission form.

Participant Name

First Name

Last Name

Choose how the participant 14 and under may leave the YWCA Yonkers premises:

Children under 14 years of age may not leave the YWCA of Yonkers premises unaccompanied by an adult (at least 18 years old) authorized by you. Please list below the names of persons authorized to pick-up /drop-off your child.

I understand the YWCA of Yonkers’ policy regarding children under the age of 14. I am fully responsible for transportation to and from the YWCA of Yonkers and permit my child to get to and leave the YWCA of Yonkers unaccompanied by an adult. Further, I exempt the YWCA of Yonkers from liability for any injury that may occur while she is on the way to/from the YWCA of Yonkers.

I agree to inform the YWCA of Yonkers of any changes in the information provided above and agree that the YWCA of Yonkers will not be liable for any injury arising from my failure to provide such information.

Parent/Guardian Electronic Signature

First Name

Last Name

Date

MM

DD

YYYY

PEARL Code of Conduct

(Filled out by Participant)

PEARL Applicant Questionaire

Applicant overview

First Name

Last Name

In a couple of sentences, tell us about yourself:

What would you like to become as an adult?

Who is the most influential person in your life and why?

Do you currently attend an after school program?

Yes

No

What do you do on your spare time?

What do you usualy do for the summer? What would you like to do next summer?

In two sentences, how do you think you relate to adults?

Why do you want to join this program?

What do you hope to gain from this program?

What do you think you can contribute to this program?

What activities would you like to see offered?

Do you have any special skills you would like to share?

Register for P.E.A.R.L.

Join the P.E.A.R.L. Program

EMERGENCY MEDICAL RELEASE FORM:

GENERAL RELEASE FORM:

CONFIDENTIAL INFORMATION RELEASE:

FIELD TRIPS:

Photo Release for Press/Socials/Marketing:

PEARL Code of Conduct

CODE OF BEHAVIOR PROMISE

I (Participant) promise that during every minute of every day during this program:

PEARL Applicant Questionaire

That’s it! Thank you so much for your interest in our program. We will be in touch!

Reach out:

Call (914) 963-0640