Tri-County Ymca Afterschool Program Registration Form - 2016-2017
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3Tri-County YMCA
Afterschool Program
Registration Form 2016-2017 School Year
PLEASE INDICATE AFTERSCHOOL LOCATION ATTENDING: Jasper____
Ferdinand____
Pine Ridge____
PLEASE CHECK IF THE CHILD IS A: ____ YMCA Member
OR
____ Program Participant
CHILD 1:
CHILD 2:
____________
______________
____________
______________
First
Last
First
Last
___/___/___
____
___/___/___
____
Birthdate
Age
Birthdate
Age
2016-2017 Grade _____
Gender _____
2016-2017 Grade _____
Gender _____
___________________
___________________
School Attending
School Attending
______________
______________
Special Conditions/Needs
Special Conditions/Needs
_________________________________
_________________________________
_________________
_________________
Medications/Allergies
Medications/Allergies
__________________________________
__________________________________
Parent/Guardian Information:
Child Pick-up information:
Parent/Guardian(s) listed at the left are authorized to pick up child(ren),
unless otherwise noted. You may also authorize the people named below to
1. Guardian Name______________________
pick up your child(ren). For your child’s safety, he/she will be released ONLY
Relationship___________ D.O.B.__/__/__
to those listed on the page. Changes to this list must be made in writing and
may only be done by the parent or legal guardian.
Address___________________________
City___________ St______ Zip________
1. Name____________________________
Primary Phone____________________
Address_____________________________
Alternate Phone___________________
Primary Phone________________________
Place of Employment___________________
Alternate Phone_______________________
Email Address________________________
Relationship__________________________
2. Guardian Name______________________
2. Name____________________________
Relationship___________ D.O.B.__/__/__
Address_____________________________
Address___________________________
Primary Phone________________________
City___________ St______ Zip________
Alternate Phone_______________________
Primary Phone____________________
Relationship__________________________
Alternate Phone___________________
Place of Employment________________________
3. Name____________________________
Email Address_____________________________
Address_____________________________
Primary Phone________________________
Alternate Phone_______________________
Relationship__________________________
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