BTB Fall 2023 Scholarship Registration Form
Please complete this scholarship registration form and submit with cash or a check payable to “South Mountain YMCA" to Main Office no later than September 19th.  Address envelope to Beyond the Bell Enrichment Program.  
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School *
Child's Name (First Name and Last Name) *
Teacher *
Grade *
Street Address *
Town *
Parent/Guardian's Name #1 (First and Last Name) *
Email Address #1 *
Cell Phone *
Parent/Guardian's Name #2  (First and Last Name)
Email Address #2
Cell Phone
ALLERGIES: My child is allergic to:
Does your child have an epi-pen? *
Does your child have a paraprofessional as part of their IEP or 504? *
Please share any information about your child that would help to ensure your child has a great BTB experience.
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