Enrollment/emergency Information Form - Safe 'N Sound

HEALTH HISTORY

Please list any allergies (including food) your child has and associated symptoms. _________________________________________________________________

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What special aids, devices or medication does your child require during the program hours? Please complete the additional

medication form so it may be administered.

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Describe any of your child’s current health conditions that require medical attention, treatment, or special restrictions or

considerations while at Safe ‘n Sound.

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SOCIAL CHARACTERISTICS

How would you describe your child’s personality? (i.e. aggressive, friendly, shy, withdrawn, sociable, etc.) __________________________

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Does your child have any special needs that we should be aware of to better understand and work with your child? (Please be

specific.)

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Does your child have any fears that we should be aware of? (i.e. storms, dogs, etc.) _____________________________________________________

How does your child behave when angry or upset? __________________________________________________________________________________________________

What is the best way to make him/her feel better? __________________________________________________________________________________________________

In what ways can we work together to help your child in such areas as sharing, speaking, accepting corrections, assertiveness,

listening or following directions? ________________________________________________________________________________________________________________________

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Have there been any events in your child’s life that have been particularly upsetting? ___________

Explain: _________________________________________________________________________________________________________________________________________________________

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Parent/guardian assumes all risks of injury arising out of his or her presence on or about the premises or at another location,

use or intended use of equipment and facilities, or his or her participation in the activities of the B.R. Ryall YMCA, an Illinois

chartered not for profit corporation and does hereby for himself, herself, heirs, executors and administrators waive, release,

and agree to hold free from all claims for damages the B.R. Ryall YMCA, and its respective officers, directors, Trustees, Board of

Directors, members, employees, or agents.

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Signature of Parent /Guardian

B.R. RYALL YMCA

| 49 Deicke Dr. | Glen Ellyn, IL 60137 | 630.858.0100 |

of Northwestern DuPage County