SAC/SOC Child Information Form

Current Child's Information
Authorized Adults for Pick-Up
Questions/Comments
Waiver Form
Complete

Child's Information

Please fill out this form for each of your children registered for any of the following programs at the Y:

Before School Care
After School Care
School's Out Club (full day care at the Y)

This information will be provided to the Y staff who are supervising your child at the school or at the Y.

Child's Information

Child's Information
Name Age Date of Birth Entering Grade School

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

This child is registered for:

Before School Care

After School Care

School's Out Club

Promotional Agreement

Yes

The Two Rivers YMCA and its funding partners have my permission to use photographs or videos of my child in YMCA promotional materials.

Internet Usage

Yes

I give permission for my child to use the internet under the supervision of the Y staff.

Floatation Device

Yes

My child needs a flotation device when swimming at the Y.

Sunscreen Application

Yes

I give permission to Y staff to help apply sunscreen on my child. I understand they will not apply sunscreen to any part of the body a swimsuit covers.

Accommodations

Please list any special needs (health, physical, dietary, educational, behavioral, etc)

Allergies

Please list any allergies.

Medications

Please list all current prescription medications.

Limited or Encouraged Activities

Please describe any specific activited to be encouraged or limited by physician's advice.