YWCA Camp Cares
Thank you for your interest in YWCA's Camp Cares which blends the traditional camp experience with community service learning opportunities. We are so excited your family will be joining us this summer!
Email address *
CAMPER INFORMATION
CHILD'S FIRST NAME *
Your answer
CHILD'S LAST NAME *
Your answer
CHILD'S DATE OF BIRTH *
MM
/
DD
/
YYYY
CHILD'S AGE *
Your answer
ADDRESS (Street, Apt, City, State) *
Your answer
NAME OF SCHOOL CHILD ATTENDS *
Your answer
GRADE (Entering Fall 2019) *
GENDER *
Required
RACE/ETHNICITY *
Your answer
ADDITIONAL INFORMATION ON CHILD (swim level, interests, etc.)
Your answer
T-SHIRT SIZE *
HOW DID YOU HEAR ABOUT US? *
MEDICAL INFORMATION
NAME OF CHILD'S PHYSICIAN/ MEDICAL CARE PROVIDER *
Your answer
PHYSICIAN TELEPHONE NUMBER *
Your answer
PHYSICIAN ADDRESS (street, apt., city, state, zip) *
Your answer
NAME OF HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS *
Your answer
POLICY NUMBER *
Your answer
MEDICAL OR DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION
Your answer
ALLERGIES (including medication reaction)
Your answer
SPECIAL NEEDS (If any)
Your answer
PARENT INFORMATION
NAME (First, Middle Initial, Last) *
Your answer
RELATIONSHIP TO CHILD *
PRIMARY CONTACT NUMBER *
Your answer
SECONDARY CONTACT NUMBER *
Your answer
EMAIL ADDRESS *
Your answer
NAME (First, Middle Initial, Last)
Your answer
RELATIONSHIP TO CHILD
PRIMARY CONTACT NUMBER
Your answer
SECONDARY CONTACT NUMBER
Your answer
EMAIL ADDRESS
Your answer
EMERGENCY CONTACTS
In event of an emergency, we will attempt to contact a parent. Please provide at least two additional people who have authority to make all decisions regarding your child if we are unable to reach a parent or guardian.
(1 Emergency Contact) First/Last Name, Relationship, Phone Number: * *
Your answer
(2 Emergency Contact) First/Last Name, Relationship, Phone Number: * *
Your answer
(3 Emergency Contact) First/Last Name, Relationship, Phone Number: *
Your answer
PERSON(S) TO WHOM CHILD MAY BE RELEASED (Other than parent/legal guardian)
Please list 3 additional people besides the parent/guardian who can pick up your child

(1 Pick Up) First/Last Name, Relationship, Phone Number: * *
Your answer
(2 Pick Up) First/Last Name, Relationship, Phone Number: * *
Your answer
(3 Pick Up) First/Last Name, Relationship, Phone Number: * *
Your answer
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