This 3 sentence summary provides the key information from the 2012 Child Care Services Branch Youth Information Form:
The form collects a child's personal information such as name, address, birthdate, medical information, emergency contacts, and parental consent for activities and transportation for their participation in the 2012-2013 Summer Camp and Afterschool Programs. Sections include the child's profile, family information, medical details, swimming ability, expectations for the programs, and authorized pick-up contacts in case of emergency when a parent is unavailable.
This 3 sentence summary provides the key information from the 2012 Child Care Services Branch Youth Information Form:
The form collects a child's personal information such as name, address, birthdate, medical information, emergency contacts, and parental consent for activities and transportation for their participation in the 2012-2013 Summer Camp and Afterschool Programs. Sections include the child's profile, family information, medical details, swimming ability, expectations for the programs, and authorized pick-up contacts in case of emergency when a parent is unavailable.
This 3 sentence summary provides the key information from the 2012 Child Care Services Branch Youth Information Form:
The form collects a child's personal information such as name, address, birthdate, medical information, emergency contacts, and parental consent for activities and transportation for their participation in the 2012-2013 Summer Camp and Afterschool Programs. Sections include the child's profile, family information, medical details, swimming ability, expectations for the programs, and authorized pick-up contacts in case of emergency when a parent is unavailable.
This 3 sentence summary provides the key information from the 2012 Child Care Services Branch Youth Information Form:
The form collects a child's personal information such as name, address, birthdate, medical information, emergency contacts, and parental consent for activities and transportation for their participation in the 2012-2013 Summer Camp and Afterschool Programs. Sections include the child's profile, family information, medical details, swimming ability, expectations for the programs, and authorized pick-up contacts in case of emergency when a parent is unavailable.
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2012 Child Care Services Branch Youth Information Form
This youth information is effective for the 2012-2013 Summer Camp and Afterschool Programs. Childs Information Childs name___________________________________________________________________________ Address _____________________________________________________ City ____________________ Zip ___________ ___ Male ___Female Birth date _________________
Age (as of June 2012) _____ Ethnicity ______________________
School child attends during school year _________________________________Grade (as of Aug. 2012) ______________ 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 medications will need to be administered at the Y program): __________________________________________________________________________________________________________________________________ Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):_________________________________________________________ What activities 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 ____________________________________________________________(please provide the email address that we may use for contacting you) Home address _________________________________________________________________ City ________________________________ Zip _____________ Home # _______________________ Work # _______________________ ext. _______ Mobile # _______________________ Pager # ____________________ ___ Parent/guardians name _________________________________________________________________ Employer ________________________________ E-mail address ____________________________________________________________(please provide the email address that we may use for contacting you) Home address _________________________________________________________________ City ________________________________ Zip _____________ Home # _______________________ Work # _______________________ ext. _______ Mobile # _______________________ Pager # ____________________ Emergency Information(If you do not have a doctor/dentist, please list Buncombe County Health Department or another provider of your choice. 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 # _________________________________ 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 # _____________________ ext. ____ Mobile # __________________ Pager # ____________
2.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
3.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
4.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
