Skip to main content
  • 1 Current Child's Information
  • 2 Authorized Adults for Pick-Up
  • 3 Questions/Comments
  • 4 Authorized Signature
  • 5 Complete
Indicates required field

Child's Information

Please submit this form once for each of your children that you would like to register for Summer Camp.

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

This form does not guarantee your child's spot in camp. (Your child's spot is reserved for each day that is paid for in advance.)

 

Child's Information
My child will primarily attend camp at this location:
Two Rivers YMCA
Rock Island site (Tri-City Jewish Center)
Promotional Agreement
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
I give permission for my child to use the internet under the supervision of the Y staff.
Floatation Device
My child needs a flotation device when swimming at the Y.
Sunscreen Application
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.
Please list any special needs (health, physical, dietary, educational, behavioral, etc)
Please list any allergies.
Please list all current prescription medications.
Please describe any specific activited to be encouraged or limited by physician's advice.