Young Women Empowered · 2024 Black Girls Swim/Black Mermaids Camp

Y-WE Welcomes...

*Y-WE welcomes those who identify as a girl/woman, nonbinary, trans, and gender expansive. Most programs are open to youth ages 13-19.

Youth Information

Please look over the application below and prepare to complete and submit it in one session. You WILL NOT be able to save the form mid-way through.

Preferred First Name

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Last Name

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Pronouns

she/her, they/them, he/him, etc

Legal name (if different)

Birthdate

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(mm/dd/yyyy)

Age

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Email

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Verify Email

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Phone Number

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May we text you at this number?

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Yes

No

Home Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

What grade are you in this year? (2023 - 2024 school year)

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If you are in school, what school do you attend?

Do you have any dietary restrictions or food allergies?

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For example: vegetarian, halal, allergic to strawberries, etc. Please note if any allergies are severe and if you carry an epi-pen!

Please describe:

Do you have any medical concerns or other major allergies you would want us to know about in an emergency?

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Your personal medical information is always kept private and confidential!

Please describe:

Do you have any accommodation needs to make programs accessible and comfortable?

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Disability accommodations, environmental sensitivities, neurodivergence accommodations, etc

How can we best support you in this area?

Youth Interests Information

Your answers to these questions help us to get to know you better and understand what inspired you to apply to Y-WE. We shape our programs around the passions and goals of the youth who participate, so your answers to these questions really matter to us!

Will this be your first Y-WE program/event?

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If you selected 'other' please describe (optional):

What made you interested in this program, and what are you hoping to gain from participating?

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Do you anticipate any scheduling conflicts or anything that would impact your ability to attend all of the program dates?

Visit the website to see all program dates!

Is there anything else you would like us to know about your family, your schedule, or your commitment to this program?

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Please upload a picture of yourself that you like (file size under 10MB please!)

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Please note: larger file sizes might slow down the processing of this form when you hit the 'submit' button at the bottom- keep the window open until you see the confirmation message!

Youth Demographic Information

YY-WE collects this data to better understand who we serve, and to improve and obtain support for our programs. Your answers are confidential and we never shares personal or identifying information outside of Y-WE!

Do you identify as Black, Indigenous, or a Person of Color?

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OPTIONAL: If you selected 'Other' please describe:

OPTIONAL: Tribal Affiliation

OPTIONAL: If you selected 'Other' please describe:

Do you identify as LGBTQIA+?

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OPTIONAL: If you selected 'Other' please describe:

Place of Origin

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Your answers are confidential! We do not ask for or keep any record of immigration status.

Primary Household Type (where you live all or most of the time)

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OPTIONAL: If you selected 'Other' please describe:

Are you eligible for free or reduced school lunch?

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Parent/Caregiver Info

Please fill this section out completely so we can contact you about your young person's upcoming programs with us, and in case of emergency.

Parent/Caregiver Name

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First Name

Last Name

Relationship to Youth

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Parent/Caregiver Phone Number

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Alternate Phone Number (optional)

Parent/Caregiver Email Address

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Verify Email

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Alternate Email Address (optional)

Verify Email

Do you live at the same address as your young person?

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Parent/Caregiver(s) Primary Address (if different from youth's home address)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Please tell us a bit about why you are encouraging this young person to sign up for Y-WE, and if there's anything you'd like us to know about them.

Y-WE must have Hold Harmless and Medical forms for each participant before the program begins, signed by a parent/guardian. Youth 18+ can fill out these forms on their own behalf. These forms will be sent to you to fill out before the program

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I understand

Needs Support Check-In

Y-WE's Community Wellness and Mental Health team help connect Y-WE individuals and families with mental health and wellness support. These services are confidential. If you or your family is in need of immediate support, please email wellness@y-we.org.

Wellness and Mental Health Support

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Is there anything you would like us to know about you or your family's wellness and mental health needs?

If yes, please describe:

2024 Y-WE Black Mermaids Summer Swim Camp

August 20-24th, 1-4pm daily. Location TBD.

If you have any needs or questions, contact Beatriz Rojas Vazquez at Beatriz@y-we.org.

Y-WE Welcomes...

Youth Information

Youth Interests Information

Youth Demographic Information

Parent/Caregiver Info

Needs Support Check-In