Martinsville-Henry County Family Ymca 2015-2016 School Year Form Page 2
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7Martinsville-Henry County Family YMCA 2015-2016 School Year
COMPLETE THIS ENTIRE FORM
(Every Line MUST be filled or marked “N/A” for Not Applicable)
Site Attending:
□ My child may participate in Y School Day Out Camp
□ Full-time Care (4-5 days per week)
□ Part-time Care (3 or less days per week)
Last Name
First Name
Nickname
Middle Int.
Address (911 Physical Address)
City
State Zip Code
Home Phone Number
E-mail address:
□ Male □ Female
______
Date of Birth
Age
School Attending and Grade as of September 2015
NAME OF LEGAL GUARDIANS
ADDRESS (must provide a 911
HOME &
WORK #
EMPLOYER
address: street, city, state, & zip)
CELL #
Name:
□Mother □Step-Mother
□Other
Name:
□Father
□Step-Father
□Other
Please provide 2 Emergency Contacts for when legal custodians may NOT be reached
Requires 2 Emergency Contacts that ARE NOT legal custodians
EMERGENCY CONTACT PERSON
ADDRESS
HOME &
WORK #
RELATIONSHIP
(must provide a 911 address: street, city,
CELL #
state, & zip)
Name:
Name:
At time of registration, you must list all persons authorized to pick up your child. It is imperative that all persons
who are authorized to pick up your child (including parents) be listed here. Only persons 18 years or older can
pick-up children. A valid ID will be required when picking up children.
Authorized to Pick Up:
Relationship to Child:
Authorized to Pick Up:
Relationship to Child:
1)
4)
2)
5)
3)
6)
Please list anyone NOT authorized to pick up your child
(biological parents CAN NOT be listed unless the appropriate legal/custody papers are provided):
NOT Authorized to Pick Up:
Relationship to Child:
NOT Authorized to Pick Up:
Relationship to Child:
1)
4)
2)
5)
3)
6)
Date Entered Care:
Date Left Care:
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