2012 YMCA of WNC Hendersonville Branch

Winter Break Camp Youth Information Form

This youth information is effective for the 2012-2013 YMCA Hendersonville Winter Break Camp Program.
Childs Information
Childs name________________________________________________________________________
Address _____________________________________City ____________________ Zip ___________
___ Male ___Female

Birth date _______________Age (as of August 2012) _____ Ethnicity__________

School child attends _________________________________Grade (as of Aug. 2012) ______________

Allergies (please be specific and note level of severity, etc.):
________________________________________________________________________________
Current Medications (please note all medications AND complete the Individualized Care Plan if medications will need to be administered at
the Y program): _________________________________________________________________________________________
Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):____________________________
_____________________________________________________________________________________________________
What activities your child would enjoy while at Winter Break Camp:________________________________________________
What are your expectations for the Winter Break Program?_______________________________________________________
Names and Ages of Siblings: ______________________________________________________________________________
Swimming Ability (check one): ___ Non-Swimmer

___ Beginner

___ Intermediate

___Advanced

Family Information (List both parents/guardians AND list first the one parent/guardian (completing this form) to contact for
payments and questions.
1st Contact Parent/Guardians name _____________________________________ Employer __________________________
E-mail address ___________________________________________________________________________________
(please provide the email address that we may use for contacting you)
Home Address ______________________________________________ City _______________________ Zip _____________
Home # _________________ Work # ___________________ ext. _____ Mobile # ________________ Pager # __________
2nd Contact Parent/Guardians name _____________________________________ Employer __________________________
E-mail address ___________________________________________________________________________________
(please provide the email address that we may use for contacting you)
Home Address ______________________________________________ City _______________________ Zip _____________
Home # _________________ Work # ___________________ ext. _____ Mobile # ________________ Pager # __________

Emergency Information (If you do not have a Doctor/Dentist, please list Henderson County Health Department or another
provider of your choice. All information is REQUIRED, including hospital preference.)
In case of emergency, please contact the following first:
____Mother/Guardian ___Father/Guardian
Childs Doctor ____________________________________________ Doctors Phone # _______________________________
Childs Dentist ____________________________________________ Dentists Phone # ______________________________
Hospital Preference _____________________________________________________________________________________
Insurance Company _____________________________________________ Policy # _________________________________
Emergency Contact Information When a parent/guardian is not available, I authorize these individuals to pick-up my child:
1. Name _____________________________ Relationship to child _____________________ Home # __________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________
2. Name _____________________________ Relationship to child _____________________ Home # __________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________
3. Name _____________________________ Relationship to child _____________________ Home # __________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________

4.

Name _____________________________ Relationship to child _____________________ Home # __________________

Work # _____________________ ext. ____ Mobile # __________________ Pager # ________________