ya14-002 registration form - kansas city ymca · young achievers . 2015-2016 registration form...
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YOUNG ACHIEVERS 2015-2016 REGISTRATION FORM INSTRUCTIONS
Greetings Parents/Guardians,
1. Please complete and sign the attached registration.
Take to the following to the nearest YMCA in the Kansas City metro area.
1. 2015 – 2016 registration form
2. Current grade card
3. Mentor application
4. Mentor recommendation form
5. $75 registration fee
Locations can be found on the reverse.
Forms of payment accepted: Cash, Check, Credit Card
*Note - There are a limit number of spaces to accept teens into the
Young Achievers program.
For questions or more information contact:
Garrett Webster
Young Achievers
Director 913.321.9622 [email protected]
We look forward to you joining the Young Achievers family!
OUR MISSION The YMCA of Greater Kansas City, founded on Christian principles, is a charitable organization with an
inclusive environment committed to enriching the quality of family, spiritual, social, mental and
physical well-being.
A UNITED WAY AGENCY
YMCA of Greater Kansas City LOCATIONS
8TH STREET FAMILY YMCA
900 N 8th Street
Kansas City, KS 66101
913.321.9622
ATCHISON FAMILY YMCA
321 Commercial
Atchison, KS 66002
913.367.4948
BLUE SPRINGS FAMILY YMCA
1300 Adams Dairy Parkway
Blue Springs, MO 64014
816.224.9620
BONNER SPRINGS FAMILY YMCA
2251 S 138th Street
Bonner Springs, KS 66012
913.422.9348
CLEAVER FAMILY YMCA
7000 Troost Avenue
Kansas City, MO 64131
816.285.9622
LINWOOD FAMILY YMCA
(In Central High School)
3221 Indiana Avenue
Kansas City, MO 64128
816.923.5675
OLATHE FAMILY YMCA
21400 W 153rd Street
Olathe, KS 66061
913.393.9622
PAUL HENSON FAMILY YMCA
4200 W 79th Street
Prairie Village, KS 66208
913.642.6800
PLATTE COUNTY COMMUNITY
CENTER NORTH
3101 Running Horse Road
Platte City, MO 64079
816.858.0114
PLATTE COUNTY
COMMUNITY CENTER SOUTH
8875 Clark Avenue
Parkville, MO 64152
816.505.2622
PROVIDENCE YMCA/
BALL FAMILY CENTER
8601 Parallel Parkway
Kansas City, KS 66112
913.378.9622
QUALITY HILL YMCA
1051 Washington
Kansas City, MO 64105
816.842.9622
RED BRIDGE FAMILY YMCA
11300 Holmes Road
Kansas City, MO 64131
816.942.2020
NORTH KANSAS CITY YMCA
1999 Iron Street
North Kansas City, MO 64116
816.300.0531
YOUNG ACHIEVERS 2015-2016 REGISTRATION FORM
Registration Fee $75. This registration is from September 1, 2015
to August 31, 2016
STUDENT INFORMATION
First Name MI Last Name
Address City State Zip
Student Phone Student Email
Gender Male Female Date of Birth / / Current School ___________Grade _______
Race: ☐American Indian ☐Asian ☐Black, African Am. ☐White ☐Latino/ Hispanic ☐Other ______________
STUDENT INSURANCE/MEDICAL INFORMATION
Physician’s Name Phone (required)
Insurance Group # ___ Phone
Name of Insured Relationship Hospital of Choice
Does your child have any ALLERGIES or MEDICAL CONDITIONS that should be considered? ☐Yes ☐No
If yes, please specify
Are there any SPECIAL INSTRUCTIONS or RESTRICTIONS from you or the child’s doctor? ☐Yes ☐No
If yes, please list
ROUTINE MEDICATIONS
The student takes medications on a routine basis Yes NoIf Yes, Explain ____________________________
Please attach list ALL routine medications and reasons, including non-prescription, taken routinely. The YMCA prefers that all
medications be administered at home. However, if it is necessary, please send enough medication to the last the entire season. Keep it in the original packaging that identifies the prescribing physician (prescription drugs only), the name of the medication, the dosage and the frequency of administration.
PARENT INFORMATION Parent/Guardian #1 First Name _________ Last Name __________________________Guardian ☐Yes ☐No
Parent/Guardian #1 Phone _______________ Email _________________________________________
Parent/Guardian #2 First Name MI Last Name Guardian ☐Yes ☐No
Parent/Guardian #2 Phone _______________ Email _______________________________________________
Parent/Guardian Home Address City State Zip
If parents are divorced, who is Custodial Parent? If there are special circumstances involving visitation and pick up rights, you must provide the YMCA Director with legal documentation for those arrangements.
EMERGENCY INFORMATION In case of emergency, after attempting the above phone number(s), please list the name of each person who is authorized to
act for the parent/guardian in an emergency.
Contact Name Relationship
Work Phone Home Phone Cell
Other than those listed above, who may pick up your child?
Name Relationship Phone
Name Relationship Phone
Office Use Only - Activity #133392 Date Input: ___________________ Assoc. Name: ___________________ Center: ___________________
[email protected] had emotional or psychological diiculties for which professional help was sought Yes No
HEALTH INFORMATION This information is necessary to have on file in the event your child should suddenly become ill. Please attach a separate
sheet of paper listing any additional information that you feel would be helpful to the staff working with your child.
Please place a CHECK MARK by ALL conditions that may apply to your child.
MEDICAL HISTORY
Ever had a reaction to a TB skin test ☐Yes ☐No
Been with anyone having TB ☐Yes ☐No
Ever been hospitalized ☐Yes ☐No
Ever had surgery ☐Yes ☐No
Any recent injury, illness or infectious disease ☐Yes ☐No
Chronic or recurring illness or condition ☐Yes ☐No
Which of the following has your child had?
☐Measles ☐Chicken Pox ☐German Measles ☐Mumps ☐Hepatitis ☐Varicella Zoster
My child’s immunization records are on file at School and are up to date.
Date of last doctor’s visit (mo/yr) Doctor’s Name
HEAD/CHEST (Check all that apply)
☐Frequent headaches
☐Has tubes in hears
☐Ever had a head injury
☐Frequent ear infections
☐Been knocked unconscious
☐Ever been dizzy during or after exercise
☐Ever had seizures, Fits or shaking spells?
☐Ever passed out during or after exercise
☐Ever had chest pains during or after exercise
DIAGNOSED CONDITIONS (Check all that apply)
☐High blood pressure ☐Ever been diagnosed with heart murmur ☐Ever been diagnosed with diabetes
☐Ever been diagnosed with asthma ☐Had problems with diarrhea/constipation ☐ADD or ADHD
☐Have had skin problems (i.e., itching, rash, acne) ☐Ever had a bladder infection ☐Ever had a kidney infection
SPECIAL CHARACTERISTICS OR CONDITIONS Any problems with speech ☐Yes ☐No Any problems with vision ☐Yes ☐No Any problems with hearing ☐Yes ☐No Has allergies ☐Yes ☐No Has an eating disorder ☐Yes ☐No Any reactions to medicine ☐Yes ☐No
Any reactions to DPT ☐Yes ☐No Any reactions to insects ☐Yes ☐No Hemophiliac (free bleeder) ☐Yes ☐No
My child is generally happy ☐Yes ☐No My child is generally sad ☐Yes ☐No Respects authority ☐Yes ☐No Has reading limitations ☐Yes ☐No Participates in special education classes in school ☐Yes ☐No
Has a good attitude towards school ☐Yes ☐No Has difficulty with adult/child relationships ☐Yes ☐No
STATEMENT OF UNDERSTANDING, PERMISSION & WAIVER
My child has permission to participate in all YMCA of Greater Kansas City Youth Development activities, including field trips and transportation, where
applicable. The health history provided is correct as far as I know, and my child named above has permission to engage in all activities except as noted. I
grant permission for YMCA staff to monitor my child’s behavior and performance in school and to obtain copies of report cards, attendance, disciplinary,
and other school records as it relates to program goals. I understand that my child is solely responsible for his/her actions. Therefore, if actions warrant,
and my child’s behavior is not acceptable (according to YMCA guidelines), I understand that my child may be sent home at any time and at my expense. I
grant permission for photographs, written/art work, quotes, videos or other media which may include my child, to be used in media releases which
benefit the YMCA. In the event of an emergency, I hereby give permission to the physician selected by the YMCA to order x-rays, routine tests, and
treatment for the health of my child. In the event that I cannot be reached in an emergency, I give permission to the physician selected by the YMCA to
secure proper treatment for, hospitalize, and/or to order injections, anesthesia, or surgery if necessary. In the event it becomes necessary for the YMCA
staff to give consent for us, we agree to hold such person and the YMCA free and harmless of any claims, demands or suits for damages arising from the
giving of such consent so long as the treatment is administered by or under the supervision of a licensed physician. By signing this form, I expressly
assume the risk of damage or harm to person or property. Accordingly, neither the YMCA nor any of its agents, employees, volunteers, or invitees shall be
liable to me or any of my family, agents, employees, volunteers, servants, or invitees for any damage to persons or property when and to the extent that
any such damage or injury may be caused, either proximately or remotely, wholly or in part, by any act or omission, whether negligent or not, of the
YMCA or any of its agents, employees, volunteers, or invitees or due to the condition, design, or defect in the building, its mechanical systems, or its
equipment. I understand this registration is from September 1, 2015 to August 31, 2016.
Print Name of Parent/Guardian ______________________________ Phone____________________
Signature of Parent/Guardian Date
The YMCA is a non-discriminating organization and we welcome all participants regardless of race, sex, origin and handicapping condition.
OUR MISSION The YMCA of Greater Kansas City, founded on Christian principles, is a charitable organization with an inclusive environment committed to enriching the quality of family, spiritual,
social, mental and physical well-being. A UNITED WAY AGENCY