Holiday Camp Registration 2016-2017
Holiday Camp Registration 2016-2017 Child’s Name____________________________
Date of Birth_____________________
Address: _________________________________________________________________ Home Phone: _______________________ Email:_______________________________ 1st Parent’s Name:______________________________ Occupation:________________ Daytime Phone: _______________________________ Cell Phone: ________________ 2nd Parent’s Name: _____________________________ Occupation:________________ Daytime Phone:________________________________ Cell Phone:_________________ Emergency Contact Name:____________________________ Phone Number:___________________________ Relationship:______________________________ Child’s Physician:________________________ Phone Number;_________________________ Address:_______________________________ Please note any allergies or restrictions to activities your child may have: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ YMCA OF GREATER NEW YORK D 212-912-2260
GREENPOINT YMCA F 718-349-2146
99 Meserole Avenue
Brooklyn, NY 11222
W ymcanyc.org/greenpoint
Holiday Camp Registration Form (page 2) Health History Please note any operations or serious injuries your child has had: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Please note any chronic or recurring conditions/illnesses your child may have: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Does your child require eyeglasses or contacts: __________ Please list all medications your child is taking: _____________________________________________________________________________ _____________________________________________________________________________ A record of immunizations is required. Please attach to this form.
I hearby give authority to the Greenpoint Y to obtain necessary emergency care for my child with the understanding that the family will be notified as soon as possible. _____________________ Parent Name
__________________________ Signature
YMCA OF GREATER NEW YORK D 212-912-2260
GREENPOINT YMCA F 718-349-2146
99 Meserole Avenue
________________ Date
Brooklyn, NY 11222
W ymcanyc.org/greenpoint
Date of Birth_____________________
Address: _________________________________________________________________ Home Phone: _______________________ Email:_______________________________ 1st Parent’s Name:______________________________ Occupation:________________ Daytime Phone: _______________________________ Cell Phone: ________________ 2nd Parent’s Name: _____________________________ Occupation:________________ Daytime Phone:________________________________ Cell Phone:_________________ Emergency Contact Name:____________________________ Phone Number:___________________________ Relationship:______________________________ Child’s Physician:________________________ Phone Number;_________________________ Address:_______________________________ Please note any allergies or restrictions to activities your child may have: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ YMCA OF GREATER NEW YORK D 212-912-2260
GREENPOINT YMCA F 718-349-2146
99 Meserole Avenue
Brooklyn, NY 11222
W ymcanyc.org/greenpoint
Holiday Camp Registration Form (page 2) Health History Please note any operations or serious injuries your child has had: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Please note any chronic or recurring conditions/illnesses your child may have: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Does your child require eyeglasses or contacts: __________ Please list all medications your child is taking: _____________________________________________________________________________ _____________________________________________________________________________ A record of immunizations is required. Please attach to this form.
I hearby give authority to the Greenpoint Y to obtain necessary emergency care for my child with the understanding that the family will be notified as soon as possible. _____________________ Parent Name
__________________________ Signature
YMCA OF GREATER NEW YORK D 212-912-2260
GREENPOINT YMCA F 718-349-2146
99 Meserole Avenue
________________ Date
Brooklyn, NY 11222
W ymcanyc.org/greenpoint
