Ymca Child Watch Registration Form printable pdf download

Child Watch

Registration Form

Completed registration form must be accompanied by:



Copy of Birth Certificate



School Entrance Health Form (including physical and immunization records)

Child’s First Name__________________________________________________ MI___________ Last Name____________________________________________ Gender__________

Address____________________________________________________________ City__________________________________________ State________________ Zip__________________

Home Phone_______________________________________________________ Age____________ DOB_________/________/_____________ Current Grade____________________

Please list all other schools or programs that your child attends______________________________________________________________________________________

Parent/Guardian Name_________________________________________________________________ Home Phone_______________________________________________________

Cell Phone__________________________________________________________ Email_____________________________________________________________________________________

Employer Name & Address_________________________________________________________________________ Work Phone___________________________________________

Parent/Guardian Name_________________________________________________________________ Home Phone_____________________________ __________________________

Cell Phone__________________________________________________________ Email_________________________________________________________________ ____________________

Employer Name & Address_________________________________________________________________________ Work Phone___________________________________________

Who has legal custody of child?_____________________________________________________________________________________________________________________________

EMERGENCY INFORMATION:

The following people should be contacted in case of an emergency; only if a parent/guardian cannot be reached. Emergency contacts

should be two additional individuals other than parents/guardians; with different addresses and phone numbers.

Emergency Contacts:

Name__________________________________________________________________

Relationship to Child______________________________________________________________

Address_______________________________________________________________

Phone_________________________________Alt. Phone__________________________________

Name__________________________________________________________________

Relationship to Child______________________________________________________________

Address_______________________________________________________________

Phone_________________________________Alt. Phone__________________________________

The following people are authorized to pick-up child (Name/Relationship to child/Phone):

1)_______________________________________________________________________

2)______________________________________________________________________________

3)_______________________________________________________________________

4)______________________________________________________________________________

Unauthorized to Pick-up child: ___________________________________________________________________________________________________________________________

Please list any allergies or intolerance to food, medication, etc., and any action to take in an emergency

Physician Information:

Family Doctor__________________________________________________________________

Phone Number _________________________________________________________

Address_______________________________________________________________

OFFICE USE:

Date Enrolled: _________/________/_____________

Fees Collected: ___________________

Staff Initials_________________