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 # ____________
