The Ymca General Information, Medical History & Release Forms printable pdf download

GENERAL INFORMATION, MEDICAL HISTORY & RELEASE FORMS

Please indicate which camp(s) your child is registered for:

__________________________________________________________________________________________________________________________________________________________________________________

Participant Information

Last Name ___________________________________________________________ First Name __________________________________ Gender _________ Birthday _________________ Grade __________

Address _________________________________________________________________________________ City _____________________________________ State ____________________ Zip ______________________

Parent/Guardian Information

Last Name ______________________________________________________________________ First Name _____________________________________________ Relationship _____________________________

Address _________________________________________________________________________________ City _____________________________________ State ____________________ Zip ______________________

Cell Phone ____________________________________ Alternate # ____________________________________ Email _________________________________________________________________________________

Last Name ______________________________________________________________________ First Name _____________________________________________ Relationship _____________________________

Address _________________________________________________________________________________ City _____________________________________ State ____________________ Zip ______________________

Cell Phone ____________________________________ Alternate # ____________________________________ Email _________________________________________________________________________________

Emergency Contact/Authorized Pick-Up (when parent/guardian is unavailable

)

Name ______________________________________________________________________________ Phone __________________________________________________ Relationship ____________________________

q Emergency Contact q Pick-Up q Both

Name ______________________________________________________________________________ Phone __________________________________________________ Relationship ____________________________

q Emergency Contact q Pick-Up q Both

Name ______________________________________________________________________________ Phone __________________________________________________ Relationship ____________________________

q Emergency Contact q Pick-Up q Both

Name ______________________________________________________________________________ Phone __________________________________________________ Relationship ____________________________

q Emergency Contact q Pick-Up q Both

Please address any safety issues that you feel the staff may need to know regarding custody matters or unauthorized individuals.

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B.R. RYALL YMCA

| 49 Deicke Dr. | Glen Ellyn, IL 60137 | 630.858.0100 |

of Northwestern DuPage County