2012-2013 Corpening Memorial Branch Youth Information Form
2012-2013 Corpening Memorial Branch Youth Information Form
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 _________________
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
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
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