Ymca Loudoun County Form printable pdf download

Student’s Name: ___________________________

YMCA School Site: __________________________

Program:

After School

Kindergarten Enrichment

Start Date:

End Date:

YMCA Loudoun County

Please complete all blanks on this form. Incomplete forms cannot be accepted. We are unable to provide care until all paperwork has been submitted.

Child’s Full Name

Nickname

Address (Street, City, Zip Code)

Child’s School

Date of Birth

Grade

Sex

Primary E-Mail Address

Secondary E-mail Address

Home Phone

PARENT/GUARDIAN INFORMATION

Primary Registering Parent/Guardian Name

Date of Birth

Cell Phone

Street Address

City

State

Zip Code

Place of Employment

Work Phone

Parent/Guardian Name

Date of Birth

Cell Phone

Street Address

City

State

Zip Code

Place of Employment

Work Phone

EMERGENCY CONTACTS IF PARENTS CANNOT BE REACHED (COMPLETE ADDRESS IS REQUIRED)

Emergency Contact/Name

Phone

Street Address

City

State

Zip Code

Emergency Contact/Name

Phone

Street Address

City

State

Zip Code

MEDICAL/INSURANCE INFORMATION

Child’s Physian

Physician’s Phone

Insurance Policy Name/Number

Does your child have any allergies and/or intolerances to food, medication or any other substances? What are the symptoms and action to be taken if any? Please complete

the Allergy Form

Please provide information on any chronic physical problems and pertinent developmental information and any special accommodations needed. Attach additional sheets

if necessary.

Check here if your child will be required to take medication during the MY Place program (this includes medication for allergies i.e. Epipen, Benadryl, inhalers, etc.) AND

complete Medication Authorization Forms (requires physician’s signature)

EMERGENCY MEDICAL RELEASE (Please initial ONLY one)

_____In the event of injury/serious illness, I give permission for YMCA Loudoun County staff to obtain medical treatment for my child. I understand that if

my child needs to be transported to an emergency facility that decision will be made by the emergency team responding to the call.

OR _____ In the event of injury or serious illness, I do not give permission for YMCA staff to obtain medical treatment for my child. Instead, I instruct

YMCA staff to_________________________________________________________________________________________________________________.

ADDITIONAL INFORMATION

Authorized Person(s) for pick-up (in addition to parents and emergency contacts)

NOT Authorized Person(s) for pick-up (appropriate legal paperwork must be provided when the custodial parent requests not to release the child to the other

parent)

School(s) and/or Child Care Centers previously attended

How did you hear about us?

YMCA Flyer

Website

School

Direct Mail

Friend

Other _________________________________________

By my signature I am verifying that the information provided herein is completed and accurate to my knowledge. I understand

that incomplete or inaccurate information may result in my child being suspended or removed from the YMCA program. I also

understand it is my responsibility to keep contact and emergency information current.