Ymca Child Information Sheet printable pdf download

Child Information Sheet

Child’s Full Name:_______________________________________ Nickname:___________________

Age: _______ Grade:_______ Any siblings at YMCA:________________________________________

Mother’s Name:_________________________ Phone #1:_______________ Phone #2:____________

Father’s Name: _________________________ Phone #1:_______________ Phone #2:____________

Additional Emergency Contacts

1. __________________________________________ Phone # ____________________

2. __________________________________________ Phone # ____________________

Personality:

Shy

Quiet

Aggressive

Bully

Leader

Does child interact well with other children?_______ Does child have any fears?___________________

Does your child have any special needs?___________________________________________________

Regarding camp, my child is:

Excited

Apprehensive

Nervous

Upset

What would you and your child like to get most from his/her camp experience? ___________________

__________________________________________________________________________________

Does your child have any hobbies, special interests or skills? __________________________________

Appetite:

Above Average

Average

Below Average

Is your child sensitive about his/her size, weight, or any other characteristics? ____________________

Does your child have any allergies? ______ If yes, please specify: ______________________________

If allergy occurs, what steps should staff take?______________________________________________

Health:

Above Average

Average

Below Average

Health History (Please check if your child has/had any of the following):

Asthma

Convulsions

Diabetes

Frequent Ear Trouble

Fainting Spells

Frequent Headaches

Frequent Sore Throats

Heart Trouble

Frequent Colds

Kidney Trouble

Frequent Stomach Aches

Other, Please specify:____________________________

Does your child take medications or vitamins by doctor’s orders?

Specify:_______________________

**If the child needs medication at the YMCA a medical authorization form must be completed**

At the YMCA swimming lessons are included as a part of day camp, kinder camp, and preschool. Your signature indi-

cates your permission for your child to participate. Can your child swim 25 yards unassisted? Y N

Parent / Guardian Name:_____________________________ Signature: ____________________________

Authorization



My child has permission to be transported by a YMCA vehicle and to participate in all YMCA program activities

and related field trips.



The parent/guardian authorizes the center to obtain immediate care if any emergency occurs when he/she can-

not be located immediately. I understand that in an emergency, my child might be transported in a pri-

vate vehicle.



The parent authorizes the application of sunscreen and insect repellent for their child by YMCA staff. (Please note

any adverse reactions of which you may be aware.)



The parent authorizes the use of his/her child’s picture to appear in YMCA promotionals.

By signing below, you are authorizing all of the above. If you object to any above please let us

know in writing.

Parent/Guardian Signature:__________________________________ Date: _____________

OFFICE USE ONLY

Childs Age:

Birth date:

Group Name:

Counselor:

Ymca Child Information Sheet

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