D89 Esports Enrichment Form

2023-2024 School Year: YMCA Esports Enrichment Program Enrollment Form for D89 Middle School Families
The first step in the enrollment process for the YMCA Esports Enrichment Program is to complete the following enrollment form. Once you have completed the entire form an email will be sent confirming we have received your completed enrollment form. A West Cook YMCA team member will follow up to confirm the next steps. You can register up to 4 children residing in the same household.

The YMCA follows the School District 89 Calendar. The program will not be operating on days that school is closed, including inclement weather days in which the school closes.

PARENT/GUARDIAN INFORMATION

Parent/Guardians listed on this page are allowed to pick up on a regular basis and under any condition.
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 1 Date of Birth*

MonthDayYear
Date
Parent/Guardian 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Place of Work
Parent/Guardian 1 Work Phone Number *
Please enter a valid phone number.
Parent/Guardian 1 Email Address*
example@example.com
Parent/Guardian 1 Preferred Phone*
Please enter a valid phone number.
Parent/Guardian 1 Alternate Phone
Please enter a valid phone number.
Child(ren) resides with Parent/Guardian 1*

YesNo
Would you like to add another parent/guardian? Please note: If a second parent or guardian will be picking up your child(ren), please add them here.*

YesNo

PARENT/GUARDIAN INFORMATION (Cont.)

Parent/Guardians listed on this page are allowed to pick up on a regular basis and under any condition.
Parent/Guardian 2 Name*

First NameLast Name
Parent/Guardian 2 Date of Birth*

MonthDayYear
Same residence as Parent/Guardian 1*

YesNo
Parent/Guardian 2 Place of Work
Parent/Guardian 2 Work Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Email Address*
example@example.com
Parent/Guardian 2 Preferred Phone*
Please enter a valid phone number.
Parent/Guardian 2 Alternate Phone
Please enter a valid phone number.
Child(ren) resides with Parent/Guardian 2*

YesNo

Family Information
When necessary, who should be contacted first?*

Parent/Guardian 1Parent/Guardian 2Other

Approval for West Cook YMCA Activities

Please check all the appropriate choices that you are approving or not approving.
Photo/Video Permission*

I give permission for my child(ren) to have their picture and/or video taken as part of the West Cook YMCA program. I understand that the picture or video may be displayed in marketing materials, within the facility, in the newspaper, or on other media outlets.I do NOT give permission for my child(ren) to have their picture and/or video taken for the purpose of using in marketing materials, within the facility, newspapers, or other media outlets.
Emergency Medical Authorization: The purpose of this authorization is to enable parents and guardians to authorize provision of emergency treatment for children who become ill or injured while under our supervision when parents or guardians cannot be reached.

I hereby give my consent for the administration of any medical treatment deemed necessary by our family doctor or another licensed physician at the closed hospital facility.I do NOT give my consent for the emergency medical treatment beyond basic first aid for my child. In the event of sudden illness or injury requiring emergency medical treatment, I hereby give the YMCA staff authority to do the following listed in the next question.
If you do not give consent for emergency medical treatment as listed in previous question, please list what you do give the YMCA staff the authority to do:*
I approve as checked above and know the responsibility would rely on me for any medical costs that would come up. I give authorization based on the choices made above. *

Clear
Date of Signature*

MonthDayYear
Date

Health History Form
Family Physician's Name*

PrefixFirst NameLast Name
Physician's Phone*
Please enter a valid phone number.
Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family's Dentist's Name*

First NameLast Name
Dentist Phone*
Please enter a valid phone number.
Dentist Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Serious illnesses and/or hospitalizations. If more than one child, please label by child's name.*
Special physical conditions or disabilities that may require accommodations (please be specific) If more than one child, please list by child*
Does your child need medication dispersed during program?*

Yes, please send me the medical distribution form.No

Emergency Contacts

Emergency contacts will only be contacted in the case of a situation where we need to get a hold of parents/guardians and we have not been able to. Emergency contacts will also be allowed to pick up children from the program. If anyone other than those listed will be picking up your child, you must contact Youth Development Program Staff via d89asp@westcookymca.org. Phone authorization will not be sufficient. For the safety of your child, anyone picking up your child must have a picture ID. Anyone without proper authorization will not be allowed to take your child
Emergency Contact 1 Name*

First NameLast Name
Relationship to child*

Step-parentGrandparentAunt/UncleSibling (18 years or older)Cousin (18 years or older)Family FriendOther
Emergency Contact 1 Cell Phone*
Please enter a valid phone number.
Would you like to add another emergency contact?*

YesNo

Emergency Contact 2 Name*

First NameLast Name
Relationship to child*

Step-parentGrandparentAunt/UncleSibling (18 years or older)Cousin (18 years or older)Family FriendOther
Emergency Contact 2 Cell Phone*
Please enter a valid phone number.

Do you wish to authorize additional individuals to pick up your child?*

YesNo

Additional Authorized Pick-Up

All individuals who wish to pick up your child must be listed below, excluding parents and guardians listed under general information. If anyone other than those listed will be picking up your child, you must contact Youth Development Program Staff via d89asp@westcookymca.org. Phone authorization will not be sufficient. For the safety of your child, anyone picking up your child must have a picture ID. Anyone without proper authorization will not be allowed to take your child.
Additional Pick Up 1 Name*

First NameLast Name
Additional Pick Up 1 Phone *
Please enter a valid phone number.
Conditions for releasing child (if any)
Would you like to add an additional pick-up person?*

YesNo

Additional Pick Up 2 Name*

First NameLast Name
Additional Pick Up 2 Phone*
Please enter a valid phone number.
Conditions for releasing child (if any)
Would you like to add an additional pick up person?*

YesNo

Additional Pick Up 3 Name*

First NameLast Name
Additional Pick Up 3 Phone*
Please enter a valid phone number.
Conditions for releasing child (if any)

Please submit your 2023-2024 YMCA Esports Enrichment Enrollment Form using the submit button below. If we have any questions as we process the enrollment information, we will reach out to you. If you have any questions, please do not hesitate to email us at d89asp@westcookymca.org. We will be responding to inquiries on Tuesdays and Thursdays.

Enrollment confirmations will be sent every 4 weeks leading up to final registrations by August 15th.

Thank you.
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2023-2024 School Year: YMCA Esports Enrichment Program Enrollment Form for D89 Middle School Families

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION (Cont.)

Child 1 Information

Child 2 Information

Child 3 Information

Child 4 Information

Family Information

Approval for West Cook YMCA Activities

Health History Form

Emergency Contacts

Additional Authorized Pick-Up