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2012-2013 Corpening Memorial Branch Youth Information Form

This document is a youth information form for the 2012-2013 summer camp and afterschool programs at the Corpening Memorial Branch. It collects information about the child such as name, address, age, school, allergies, medications, emergency contacts, and swimming ability. Family information is also requested including parents' names, addresses, phone numbers, and the parent to contact for payments and questions.

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40 views1 page

2012-2013 Corpening Memorial Branch Youth Information Form

This document is a youth information form for the 2012-2013 summer camp and afterschool programs at the Corpening Memorial Branch. It collects information about the child such as name, address, age, school, allergies, medications, emergency contacts, and swimming ability. Family information is also requested including parents' names, addresses, phone numbers, and the parent to contact for payments and questions.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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2012-2013 Corpening Memorial Branch Youth Information Form

This youth information is effective for the 2012-2013 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. 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 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(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 # _____________________


Mobile # __________________

2.

Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________


Mobile # __________________

3.

Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________


Mobile # __________________

4.

Name __________________________________________________________Relationship to child ___________________________________ Home # _____________________ Work # _____________________


Mobile # __________________

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