2012-2013 Corpening Memorial Branch Youth Information Form

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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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