Child Information Sheet - Ymca Page 2
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1
2C
’
,
:
HILD
S ALLERGIES
ILLNESSES OR DISABILITIES
______________________________________________________________________________
______________________________________________________________________________
A
: (P
YMCA
NY MEDICATIONS YOUR CHILD IS CURRENTLY TAKING
LEASE NOTE THAT THE
WILL NOT ADMINISTER ANY
MEDICATION CONSENT FORM)
MEDICATION TO YOUR CHILD WITHOUT A
THESE ARE AVAILABLE AT MEMBER
.
SERVICES DESK AND PLEASE REQUEST THIS AS A SEPARATE DOCUMENT REQUIRED TO REGISTER YOUR CHILD
______________________________________________________________________________
______________________________________________________________________________
O
1-5
(
):
N A SCALE FROM
HOW PROFICIENT IS YOUR CHILD AT SWIMMING
PLEASE CIRCLE
1
2
3
4
5
LIKE A ROCK
LIKE A FISH
A
NY OTHER INFORMATION OR SUGGESTIONS YOU CAN GIVE US THAT WOULD HELP US TO PROVIDE THE BEST
:
EXPERIENCE POSSIBLE FOR YOUR CHILD
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
A
YMCA
, I
S THE PARENT OR LEGAL GUARDIAN OF THE CHILD REGISTERED IN
PROGRAMS
HEREBY UNDERSTAND THAT
. I
MY CHILD WILL BE INVOLVED IN AN ACTIVITY WHICH HAS THE POTENTIAL TO CAUSE INJURY TO THE PARTICIPANTS
YMCA
,
AGREE THAT THE
AND ITS DESIGNATED INSTRUCTORS ARE NOT TO BE HELD LIABLE
LEGALLY OR FINANCIALLY
. I
,
YMCA
FOR ANY INJURY SUSTAINED DURING THESE PROGRAMS
FURTHER AGREE THAT IF THE NEED ARISES
THE
AND
.
ITS DESIGNATED INSTRUCTORS MAY SEEK LICENSED MEDICAL ASSISTANCE FOR MY CHILD
I UNDERSTAND THAT
-
OR
REGISTRATION FEES ARE NON
REFUNDABLE UNLESS A NOTE FROM A MEDICAL PROFESSIONAL IS PRODUCED
THE
.
PROGRAM IS CANCELLED BY THE YMCA
*P
*
LEASE NOTE THE YMCA DOES NOT PROVIDE REFUNDS FOR PROGRAMS
P
/
_____________________________ D
______________________
ARENT
GUARDIAN SIGNATURE
ATE
FOR OFFICE USE ONLY
Payment: _______________
Receipt #: ________________
Staff Initial: ______
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