Community Ymca Summer Registration (Page 3 of 4) in pdf

Child Information

Has your child attended any other programs?

 No

 Yes

If yes, please specify: ____________________________________________________

______________________________________________________________________

Does your child have a special diet?

 No

 Yes

If yes, please specify: ____________________________________________________

______________________________________________________________________

Any known learning/behavioral/emotional issues?

 No

 Yes

If yes, please specify: ____________________________________________________

______________________________________________________________________

Any known nervous habits or fears?

 No

 Yes

If yes, please specify: ____________________________________________________

______________________________________________________________________

Names and ages of all siblings and where they go to school.

__________________________________________________________________________________________________________

To help us provide the best possible experience please feel free to give a brief description of

your child & include any concerns.

Use additional paper as needed.

____________________________________________________________

How were you referred to the Y? __________________________________________________

Yes, I certify that the information on this application is both true and accurate and I have not left out any

information that would help the Y understand or work with my child.

YES, my child is in good health and is able to fully participate in all activities offered at the Y programs. In an

emergency I hereby give permission for the Y to take any action deemed necessary for the best interests of my child.

I also give permission for any medical personnel selected by the Y to provide needed care including any resuscitation

efforts and transportation to a hospital for care.

YES, I am aware the Parent Handbook can be found online at

This handbook

includes all Y procedures and policies. I understand it is my responsibility to read the handbook and this entire

application and I agree to abide by all terms and regulations.

YES, I give permission for the Y to use my child’s photograph for public relations and/or marketing purposes.

YES, I agree to waive/relinquish all claims and will hold the Y & any officers, agents, employees, or representatives

harmless from any and all claims which may arise from my child’s participation in any actives of the Y.

YES, I give permission for the Y to transport my child for field trips (as applicable) with advanced notice. I

understand that the transportation will be appropriately supervised. I understand that the Y and its employees

assume no liability in case of an accident outside of their authority.

Parent Signature: ____________________________________

Date: _____________

COMMUNITY YMCA

106 Titicus Road, North Salem NY 10560

P 914 276 2398 F 914 276 7683

Community Ymca Summer Registration Page 3

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