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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.