Contact Information

Address:

Maine YMCA Youth in Government

29 Town Hall Lane

Winthrop, ME 04364

Director: Lonney Steeves

Phone: 207 - 377 - 9686

* Required Fields

* First Name:

* Last Name:

* Grade:

* Years at Youth in Govt (1st, 2nd, 3rd,4th):

* School / Club / YMCA:

* Gender:

Male Female

* Age:

* Email:

Training Session:

# ONE

# TWO

#THREE

Housing Information:

Home

Hotel Arranges by Delegation

Host Family

Roomate (1 Name only)

* Parent's Name:

* Home Phone:

Cell Phone:

* Address Line 1:

* Address Line 2:

* City / Town:

* Zip:

Insurance Carrier:

Insurance Policy #

Allergies(PETS, SMOKING, FOOD):

Medications:

Medical Conditions:

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