OYC Emergency Contact Form

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Thank you for sharing contact information for your child with the Oregon Youth Center. It is helpful for OYC staff if this contact information is updated every time you move or change your phone number. If you have any questions, or would prefer a paper form, please contact OYC at director@oregonyouthcenter.org.

Email *

Name of Youth Participant *

Age and Current Grade *

Primary Street Address

Which municipality do you live in? *

Village of Oregon

Town of Oregon

Village of Brooklyn

Town of Brooklyn

Fitchburg

Dunn

Rutland

Other:

Names of Parent(s) or Guardian(s) *

Emergency Contact #1 Phone Number(s) *

Emergency Contact #2 Phone Number(s)

Parent or Guardian Email Address(es) *

Can we add this email to our mailing list for OYC updates? We will not send these emails more than once a week. *

Yes

Does your student have any known allergies? If yes, please name the allergen and any pertinent information we need to know.

Are there any medications your student takes regularly? If yes, please name the medication below.

Are there any other health, behavior, or family situation issues that we should be aware of? If yes, please describe below.

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