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<br />Chain of Lakes YMCA Summer Programs
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<br />Child's Nome _
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<br />PLEASE USE ONf fORM PfR W/LD AIID PR/IIT IIEATLY
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<br />Plr:r.<;(' [:11 ill.: wrlple~8i)' lHld [etom 18: Chain of lokes YMCA . 7690 ViIloge Drive . linD Lakes, MN 55014 . Phone: 651-795-9622 . Fax: 651-784-7135
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<br />DoteCor;r,erec
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<br />Child's First ~lnnf
<br />G ~uJe If F G:: 7 OJ B
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<br />!,'!Icdklr:ld
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<br />:JJ\I i'iUmg
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<br />_._._I"g'_lrhooll'lcI12008
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<br />Child 10S1(I~~ 'Jli~' 0 ,'/LO~~I C. f,jler i Butl-
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<br />:-"1 Oth~'
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<br />8il1hdmlo
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<br />GSlvierl!tLil(l
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<br />Are\'ou'JYMCt,tnEr~tJer; iYw, UAe,'llber=
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<br />Address
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<br />_______.____'__ Cil'j
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<br />POfGnt/G~o!dinn'\ Work Phone ':_L_
<br />#2 Purelll/Guurdicn'sFl1siriwne
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<br />Nliddlelll:112!
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<br />Pcre~'I/GucrdIGr''s Work Prol1( (_1___
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<br />__letIPLone
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<br />IS THE CHilD TAKIHG AHY MEDICATIONS? 0 "eo C \0
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<br />EMERGENCY CONTACTS AND PICK.UP AUTHORIZATION
<br />The following people should be contacted in (Qse of emergency, only if parent or
<br />guardian cannot be reached AND ore authorized to pick up the child:
<br />1" Nom(
<br />Relononshp 10 [hild
<br />Phare
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<br />__hening(~)___
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<br />NOI'le
<br />Rel(llionhi~ 10 chilc___
<br />Pholl€:Dcy(_)
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<br />lurn!iyDollor
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<br />Fomiiy De~h,1
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<br />Corrie
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<br />EV0mg':'~,
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<br />l!\ONTHJl.AltAND YEAR OF MOST RECENT IMMUNIZATIONS:
<br />OPT Poilo
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<br />E-l1c!1
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<br />HyC'; who! kinG o~o wr\,
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<br />If medication needs to be administered during the program, 0 Medkotion Permission
<br />Form must be completed. Call the YMCA for this form, or pick it up at your site.
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<br />HAS CHILD HAD ANY OF THE FOUOWING. AND IF 59. PLEASE EXPLAIN:
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<br />DS;l8cio:needs_
<br />nAlierglGsorAsmr'lo
<br />D l}!e~cr\ !estrlul~f/S
<br />DChrorifolfecwi,;illnessel__
<br />[JOper~hons or SGrIO'JS W,ILri.JS (irciuoo dote/I)
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<br />SIc1us at chic's Vil!Or, h5mil1g, c~d ~psd
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<br />Does \lJUI lhild : 11'8 G lOrnni.jri[a~:e dlSGOSC or condlMr whld': rT,il'r' ~!ro":p I;:) he 0 lisk 'J oli1:!1) ','
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<br />irl'es,;JiccSG(OI'1I':1r.i",t
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<br />S!GNIFI~AIlT INFORMATION ABOUT YOUR CHilD'S BEHAVIOR THAT
<br />WOULD BE HELPFUI.LOJ\.HO.W;
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<br />Wgiverof Uobility
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<br />Pcrenl/Gucrdllln Aufhorizotioo
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