Ymca Summer Day Camp Form - 2016 Page 6
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9INSTRUCTIONS:
PLEASE PUT
All information must but be filled in completely.
YOUR CHILD’S
Please place “N/A” in the provided spot if information
MOST RECENT
is not valid to your family.
SCHOOL PICTURE
HERE
CHILD INFORMATION & HEALTH FORM
Child: First Name _____________________________________________________MI__________Last Name __________________________________________________________
Address ___________________________________________________________________________________________ Home Phone ___________________________________________
City_____________________________________________________________________________ State ____________ Zip_____________________________ Gender _____________
Birthday _____________________________ Age _________ School ______________________________________________________________ Grade going into __________
Family’s Annual Income
Ethnic Background
Race
□ Under $10,000
□ Hispanic or Latino
□ Native American
□ $10,000 - $19,000
□ Not Hispanic
□ Asian
□ $20,000-$29,000
□ Unknown
□ Black
□ $30,000-$39,000
□ Pacific Islander
□ $40,000-$49,000
□ White
□ $50,000-$59,000
□ Other
□ $60,000 and over
□ Unknown
□ Unknown
How did you hear about us? ______________________________________________________________________________________________________________________________
Mother’s (or Guardian) First Name___________________________________________________ Last Name ____________________________________________________
Mother’s DOB____________________________________________________________________________________________(We must have this to register your child)
Address _________________________________________________________________________________________________ Home Phone _____________________________________
City _____________________________________________________________________ State ________ Zip ____________Work Phone _____________________________________
Employed By ___________________________________________________ Address __________________________________________________________________________________
Father’s (or Guardian) First Name_________________________________________________Last Name _________________________________________________________
Father’s DOB_____________________________________________________________________________________________(We must have this to register your child)
Address __________________________________________________________________________________________________ Home Phone ____________________________________
City _____________________________________________________________________ State ________ Zip ____________ Work Phone ____________________________________
Employed By ___________________________________________________ Address __________________________________________________________________________________
Name of Family Doctor ________________________________________________________________________________Phone ____________________________________________
Address __________________________________________________________________ City______________________________________ State _________ Zip __________________
Name of Dentist ________________________________________________________________________________________Phone ____________________________________________
Address __________________________________________________________________ City______________________________________ State _________ Zip __________________
YMCA OF GREATER OMAHA . . Page 6
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