Youth Impact Program » Michigan YIP Application

Michigan YIP Oct 24 - 25, 2020

Name*

First Middle Last

Email:

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

MM

DD

YYYY

Grade as of Fall 2020 (6th, 7th, 8th Grade)*

School*

School District*

Height

Weight (in lbs)

Does your child have any medical/physical conditions?

Is your child currently on medication?*

Yes
No

Please list any medications:

Does your child have any allergies?*

Yes
No

Please list any allergies:

Adult T-Shirt Size*

Adult Shorts Size*

How did you hear about the program?*

Is your child a returning participant?*

Student Essay

Please write at least 5 sentences (a paragraph) telling us why you deserve to be selected to attend the University of Michigan Youth Impact Program and how the program can help you with your future dreams.

Parent Guardian Information

Name*

Prefix First Last

Relationship to Student

Home Phone Number

Cell Phone Number*

Email*

Enter Email Confirm Email

Statement of Responsibility:

I, the Legal Guardian, understand that in completing this application, I support my child in participating in this academic and athletic program.*

Agree
Disagree

I will not schedule vacation time or admit my child into other camps during the program dates, otherwise I forfeit their spot as to allow another camper to attend.*

Agree
Disagree

Photo & Video Release for Minor Children - I authorize YIP to publish any photographs and videos taken of my undersigned minor child, for use in printed publications, website and social media sites.*

Agree
Disagree

I assume FULL risk and responsibility for their commitment and participation in this program and I agree to waive any claims against the YIP and the University of Michigan.*

Agree
Disagree

Bus Stop Location

Michigan YIP Application

University of Michigan Youth Impact Program Application 2020

Michigan YIP Oct 24 - 25, 2020

Parent Guardian Information

Statement of Responsibility:

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