2008 APPLICATION
 
FOR OFFICE USE ONLY: 

DEPOSIT $_________________________________________________________________________________________ 

PAYMENT(S)________________________________________________________________________________________

PAID IN FULL DATE_________________________________________________________________________________ 

RECEIPT # ________________________________________________________________________________________


CUMBERLAND YOUTH FOUNDATION DAY PLAYERS CAMP 

MAY 27TH – AUGUST 8TH, 2008 - 7:30 AM to 6:00 PM - MONDAY THRU FRIDAY
1505 NORTH MOORE ROAD - CHATTANOOGA, TN 37411 
PHONE (423) 698­2556 FAX (423) 629­6683
 
****YOUR $150.00 DEPOSIT IS NON­REFUNDABLE**** 

IF THIS IS YOUR CHILD’S FIRST YEAR ATTENDING CAMP, PLEASE BE SURE TO INCLUDE A COPY OF THE CHILD’S 
BIRTH CERTIFICATE. 

CHILD’S FULL NAME: ________________________________________________________ AGE: _________________ 

NAME CHILD GOES BY: _______________________________________________________ DOB: _________________ 

T­SHIRT SIZE (CHECK ONE): YOUTH (XS) (S) (M) (L) (XL) 
*Be sure you select your ADULT (S) (M) (L) (XL) child’s correct T­Shirt size as no replacement 
shirts will be issued. T­shirts will be ordered approximately 2 weeks after camp begins.  

PARENT/GUARDIAN INFORMATION 

MOTHER’S FULL NAME: _____________________________________________________________________________

ADDRESS: ________________________________________________________________________________________

CITY: ___________________________________________________________________________________________

STATE: __________________________________________________________________________________________

ZIP: ____________________________________________________________________________________________

HOME PHONE NUMBER: ______________________________________________________________________________

EMPLOYER: _______________________________________________________________________________________

WORK OR CELL PHONE NUMBER: ______________________________________________________________________ 

EMAIL ADDRESS: __________________________________________________________________________________

**PLEASE PUT THE EMAIL ADDRESS YOU CHECK MOST FREQUENTLY. 



FATHER’S FULL NAME: _____________________________________________________________________________
 
ADDRESS: ________________________________________________________________________________________ 

CITY: ___________________________________________________________________________________________
 
STATE: __________________________________________________________________________________________ 

ZIP: ____________________________________________________________________________________________ 
 
HOME PHONE NUMBER: ______________________________________________________________________________ 

EMPLOYER: _______________________________________________________________________________________ 
 	
WORK OR CELL PHONE NUMBER: ______________________________________________________________________ 
 
EMAIL ADDRESS: __________________________________________________________________________________ 

**PLEASE PUT THE EMAIL ADDRESS YOU CHECK MOST FREQUENTLY. 


TRANSPORTATION PLAN: 
To insure the safety of your child, please list other adults to whom your child may be released or 
who are authorized to provide transportation for your child.
 
Name:____________________________________________  PHONE NUMBER:_________________________________

Name:____________________________________________  PHONE NUMBER:_________________________________

Name:____________________________________________  PHONE NUMBER:_________________________________

Name:____________________________________________  PHONE NUMBER:_________________________________  


EMERGENCY INFORMATION:
(We do not have medical facilities but may need information in case of accident or illness.)
 
NAME OF PERSON AUTHORIZED TO ACT FOR PARENT IN AN EMERGENCY. (IF A PARENT CANNOT BE REACHED.) 


NAME_____________________________________________  PHONE NUMBER:_________________________________ 


ADDRESS: ________________________________________________________________________________________
 
CITY: ___________________________________________________________________________________________
 
STATE: __________________________________________________________________________________________
 
ZIP: ____________________________________________________________________________________________
 

In divorce situation, the parent with legal custody is:

 
NAME: ___________________________________________________________________________________________ 

DAYTIME PHONE NUMBER: ___________________________________________________________________________ 


OTHER CHILDREN IN FAMILY:
_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

MEDICAL INFORMATION:
 
NAME OF PRIMARY CARE PHYSICIAN: _________________________________________________________________

OFFICE HOURS:____________________________________________________________________________________

ADDRESS__________________________________________________________________________________________ 

OFFICE PHONE NUMBER: ____________________________________________________________________________ 

CITY: ___________________________________________________________________________________________ 

STATE: __________________________________________________________________________________________

ZIP: ____________________________________________________________________________________________

	
1. Is your child allergic to any medications? If so, name: 

2. Does your child have any food allergies and/or any other severe allergies? 

3. Does your child take any medications on a regular basis? If so, please provide name and schedule. 

4. Has your child had swimming lessons and how would you rate his/her skills? 

5. Health Insurance Provider ____________________________________________________________________ 


Primary Insurance Holder____________________________________________ ID # _______________________
 
Group # _________________________________________________________________________________________ 
6. 	
Please note any other medical or personal information you feel we should know about your child. 

7. 	
Is your child overly sensitive to the sun? _____YES _____ NO 

8. 	
In case of a need for emergency treatment, which hospital do you prefer? (If no hospital is noted, 
your child will be taken to Children’s Hospital.) 


ALL INFORMATION PROVIDED IS TRUE. THE CYF STAFF HAS PERMISSION TO SEEK MEDICAL 
ATTENTION FOR THE ABOVE MENTIONED MINOR IN CASE OF EMERGENCY. 

PARENT/GUARDIAN SIGNATURE: _______________________________________________________

DATE:_________________
 
COMMENTS OR ADDITIONAL INFORMATION:

__________________________________________________________________________________

__________________________________________________________________________________

**PLEASE NOTE: THERE WILL BE A MANDATORY PARENTS MEETING ON TUESDAY, MAY 20TH AT 6:00 PM IN THE 
FELLOWSHIP HALL. EVEN IF YOUR CHILD IS A VETERAN DAY PLAYER, YOU ARE HIGHLY ENCOURAGED TO ATTEND.