2024 Esports Enrollment Form

2024 Esports Enrollment Form
Welcome to Esports. To complete your registration for the Summer program, please complete the following enrollment form and payment.

For any questions or if you would like to know more about financial assistance available, please email us at youthdevelopment@westcookymca.org.

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 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 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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

Approval for West Cook YMCA Activities

Please check all the appropriate choices that you are approving or not approving.
Permission to walk home at the end of the program*

I confirm that my child(ren) is 12 years or older and has permission to sign out and walk home when the program concludes. I know that if my child needs to leave program early, a pre-approved pick-up person would have to come to sign my child out of program.I confirm that my child(ren) DO NOT have my permission to sign out and walk from home when the program concludes.
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

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 youthdevelopment@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.

My Products
prevnext( X )
4th-5th Grades: 8-Week Session: June 24-July 19Participate in all 8 weeks of the program for 4th-5th graders.
$360.00 Quantity
Item subtotal:$0.00



4th-5th Grades: 4-Week Session: June 24-July 19Participate in the first 4 weeks of the program for 4th-5th graders.
$180.00 Quantity



4th-5th Grades: 4-Week Session: July 22-August 16Participate in the second 4 weeks of the program for 4th-5th graders
$180.00 Quantity



6th-8th Grades: 8-Week Session: June 24-August 16Participate in all 8 weeks of the program for 6th-8th graders.
$480.00 Quantity



6th-8th Grades: 4-Week Session: June 24-July 19Participate in the first 4 weeks of the program for 6th-8th graders.
$250.00 Quantity



6th-8th Grades: 4-Week Session: July 22-August 16Participate in the second 4 weeks of the program for 6th-8th graders.
$250.00 Quantity



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

2024 Esports Enrollment Form

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION (Cont.)

Child 1 Information

Child 2 Information

Approval for West Cook YMCA Activities

Emergency Contacts