District 89 and West Cook YMCA Program Interest Form
Program in partnership with district 89 and the West Cook YMCA.
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
How many Children ages 3 to 18, are in your family?
Are you insured through Meridian?
Yes
No
Are you interested in the Healthy Weight and Your child program?
Yes
No
What school(s) does your child(ren) attend?
Emerson Elementary School
Garfield Elementary School
Jane Adams Elementary School
Lincoln Elementary
Roosevelt Elementary
Melrose Park Elementary School
Washington Dual Language Academy
Irving Middle School
Stevenson Middle School
Submit
Should be Empty: