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2012 Asheville YMCA Youth Information Form

This document is a youth information form for the 2012 Asheville YMCA Summer Camp and Afterschool Programs. It collects a child's personal information such as name, address, age, ethnicity, school, allergies, medications, and special needs. Family information includes parents' names and contact details. Emergency contact details include the child's doctor, dentist, hospital preference, and insurance. Authorized emergency contacts to pick up the child are also listed along with their contact information.

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ymcawnc
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© Attribution Non-Commercial (BY-NC)
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40 views

2012 Asheville YMCA Youth Information Form

This document is a youth information form for the 2012 Asheville YMCA Summer Camp and Afterschool Programs. It collects a child's personal information such as name, address, age, ethnicity, school, allergies, medications, and special needs. Family information includes parents' names and contact details. Emergency contact details include the child's doctor, dentist, hospital preference, and insurance. Authorized emergency contacts to pick up the child are also listed along with their contact information.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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2012 Asheville YMCA Youth Information Form

This youth information is effective for the 2012 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 _______________________________________(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 # ___________________

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