Emergency Contact Form : Take A Break : Youth Development Programs : Programs : YWCA of Lincoln

We want to hear from you. Please submit any questions, suggestions, or general feedback in the space below along with your name and e-mail address. We'll get back to you as soon as we can. Thank you.

Contact Information

Parent/Guardian Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2 *

City *

State/Province *

Postal Code *

Phone Number (Required)

Child(ren) Name(s) (Required)

Emergency Contact Name (Photo identification required)

First Name *

Last Name *

Emergency Phone Number (Required)

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Additional information regarding emergency procedures, if needed

Drop Off/Pickup of children

Names and relations of approved individuals (other than yourself) to transport child(ren) to and from program. (Photo identification required) (Required)

Names and relations of individuals NOT allowed to pick up children

Additional Details

Questions & Comments

Contact Information

Drop Off/Pickup of children

Additional Details

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