Northbrook Youth Programs Registration 2021-2022
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Child's Last Name
Child's First Name
Parent/Guardian Name
Street Address, City, State, Zip
Phone Number
Email
If one parent does not live with the youth or child please fill out the following information if we are to contact that parent also.
Parent/Guardian Name
Street Address, City, State, Zip
Phone Number
Email
Child's birthday
MM
/
DD
/
YYYY
Grade for the 2021-2022 School Year
Special medical concerns, allergies, current prescriptions (including instructions for taking any prescriptions if given during Camp):
Is this child covered by medical insurance?
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Carrier's Name
Carrier's Address (leave blank if same as above)
Relationship to Child
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