2008 Summer Youth Institute Application ( ages 8 - 15 )

 

Child's First Name*:

 
Child's Middle Name:  
Child's Last Name*: T-Shirt Size:
   

School Name:

School Grade in Sept 08:

Date of Birth* / /

Sex

   

 

Home Street Address*

City*:
State*:
Zip:

   

Home Phone*


Email

Parent/Guardian Information

Parent/Guardian's Name*

 

Parent/Guardian's Name

   

Home Address

Home Address

City, State, Zip Code

 

City, State, Zip Code

 

 

Cell Phone

 

Cell Phone

 

Work Phone

Work Phone

Alternative Emergency Contact

 

 

Emergency Contact's Name*

 

 

Contact Phone*

 

 

Emergency Contact's Name

 

Contact Phone

Medical Information

 

 

Physician's Name

 

 

Physician's Phone

 

 

Insurance Company

 

Policy Number

 

Allergies/Special Health Considerations

 

Prescription Medication

I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that parents/guardians or emergency contact can not be reached in the case of an emergency.
 
My child will attend:

Week 1
Week 2
Week 3

Week 4
Week 5
Week 6 		 
 

Registration Fee

Registration Fee - $60 (Non-Refundable), Tuition $200 per week (Discounts Available)

( Please make checks payable to FBCDC)