2013-2014 Corpening Memorial Center Youth Information Form

This youth information is effective for the 2012-2013 Afterschool Program.

Childs Information
Childs name________________________________________________________ Nickname _____________________________
Address _______________________________________________________ City ________________________ Zip ________________
_____ Male _____Female Birth date ________________

Age (as of Aug. 2013) ________ Ethnicity _________________

School child attends during school year _______________________Grade (as of Aug. 2013) ________________
If the Afterschool Program closes due to inclement weather, my child will:
_____ Ride the school bus home

_____ Picked up by a parent at school

Allergies (please be specific and note level of severity, etc.): __________________________________________________________________________________________

Current Medications (please note all medications AND complete the Individualized Care Plan if meds will need to be administered at the Y program):
______________________________________________________________________________________________________________________________________________________________________
Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):______________________________________________________
What are activities that your child would enjoy while at Afterschool:_______________________________________________________________________________
What are your expectations for the Afterschool/Summer Camp program?_________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
Names and Ages of Siblings: _________________________________________________________________________________________________________________________________
Swimming Ability (check one): _____ Non-Swimmer _____ Beginner _____ Intermediate _____Advanced

Family Information (List both parents/guardians AND check the one parent/guardian completing this form to contact for payments and questions.
___ 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 # __________________________
___ 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 # __________________________

Emergency Information(If you do not have a doctor/dentist, please list Buncombe County Health Department or another provider of your choice. All
information is REQUIRED, including hospital name.)
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 # _______________________________

2.

Name _________________________________________________________________________Relationship to child _________________________________________ Home # ___________________________

Work # ________________________________ ext. ____ Mobile # ________________________________

3.

Name _________________________________________________________________________Relationship to child __________________________________________ Home # ___________________________

Work # ________________________________ ext. ____ Mobile # _______________________________

4.

Name _________________________________________________________________________Relationship to child ___________________________________________ Home # __________________________

Work # ________________________________ ext. ____ Mobile # ________________________________