This document contains a youth information form for the 2013-2014 summer camp and afterschool programs at the Corpening Memorial Center. The form collects information such as the child's name, address, age, school, allergies, medications, emergency contacts, and swimming ability. It also asks who will pick up the child if the afterschool program closes for inclement weather, as well as the parents' contact information, work schedules, and expectations for the programs.
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2013-2014 Corpening Memorial Center Youth Information Form
This document contains a youth information form for the 2013-2014 summer camp and afterschool programs at the Corpening Memorial Center. The form collects information such as the child's name, address, age, school, allergies, medications, emergency contacts, and swimming ability. It also asks who will pick up the child if the afterschool program closes for inclement weather, as well as the parents' contact information, work schedules, and expectations for the programs.
This document contains a youth information form for the 2013-2014 summer camp and afterschool programs at the Corpening Memorial Center. The form collects information such as the child's name, address, age, school, allergies, medications, emergency contacts, and swimming ability. It also asks who will pick up the child if the afterschool program closes for inclement weather, as well as the parents' contact information, work schedules, and expectations for the programs.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
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2013-2014 Corpening Memorial Center Youth Information Form
This document contains a youth information form for the 2013-2014 summer camp and afterschool programs at the Corpening Memorial Center. The form collects information such as the child's name, address, age, school, allergies, medications, emergency contacts, and swimming ability. It also asks who will pick up the child if the afterschool program closes for inclement weather, as well as the parents' contact information, work schedules, and expectations for the programs.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
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2013-2014 Corpening Memorial Center Youth Information Form
This youth information is effective for the 2013-2014 Summer Camp and Afterschool Programs.
Childs Information Childs name_________________________________________________________ Nickname ____________________________________ Address __________________________________________________ City ______________________ Zip _______________ ___ Male ___Female Birth date _________________
Age (as of June 2012) _________ Ethnicity ________________
School child attends during school year ___________________Grade (as of Aug. 2013) _______________ If the Afterschool Program closes due to inclement weather, my child will: (Afterschool program use ONLY.) ___ Ride the school bus home
___ Picked up by a parent at school
___Attend YMCA Afterschool
Allergies (please be specific and note level of severity, etc.): __________________________________________________________________________________________________________
Current Medications (please note all medications AND complete the Individualized Care Plan if meds will need to be administered at the Y program): _________________________________________________________________________________________________________________________ Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):__________________________________________________________________________ What are activities that your child would enjoy while at Afterschool/Summer Camp:_________________________________________________________________________________ What are your expectations for the Afterschool/Summer Camp program?________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________ Names and Ages of Siblings: _____________________________________________________________________________________________________________ Swimming Ability (check one): _____ Non-Swimmer _____ Beginner _____ Intermediate _____Advanced
Family Information (List both parents/guardians AND check the one parent/guardian completing this form to contact for payments and questions. Parent/guardians name _________________________________ Employer ___________________________________________ E-mail address _______________________________________ Home address _________________________________________________ City _______________________ Zip _____________ Home # _________________ Work # _____________________________ Mobile # __________________ Parent/guardians name _________________________________ Employer ___________________________________________ E-mail address ______________________________________ Home address ___________________________________________________ City _______________________ Zip _____________ Home # ___________________ Work # _________________________ Mobile # __________________
Emergency Information (All information is REQUIRED, including hospital name.)
In case of emergency, please contact the following first:
____Mother/Guardian ___Father/Guardian
Childs doctor ____________________________________________ Doctors phone # _______________________
Childs dentist ____________________________________________Dentists phone # _______________________ Hospital preference ______________________________________________________________________________ Insurance company ___________________________________________ Policy # ____________________________ Parents Location when Child is in care at the YMCA ______________________________________________________________________________________________ Hours of Employment ______________________________________________________
Emergency Contact Information
When a parent/guardian is not available, I authorize these individuals to pick-up my child: 1.
Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________
Mobile # __________________
2.
Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________
Mobile # __________________
3.
Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________
Mobile # __________________
4.
Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________
