Tiningi Youth Centre Enrolment Form

Tiningi Youth Centre Enrolment Form
Young Persons Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child identify as:
Parent/ Guardian Name

First NameLast Name
Relationship to Young Person
Phone Number 1
Format: (000) 000-0000.
Phone Number 2
Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Contact Number
Format: 0000000000.
Relationship to Young Person
Does the child have any allergies?
If answered YES or ANAPHYLAXIS please provide more details:
Does your child have a diagnosed Medical or Psychological Condition; Disability or Behavioural Disorder? If YES please provide details:
SECTION 2: AUTHORISATION AND APPROVAL (permission) NOTE: Please read this section carefully. If you do not give your permission to any of the following please don't tick the box.
Parent's Signature
Name

First NameLast Name
Date Signed

MonthDayYear
Date
Should be Empty: