WASP YOUTH ENROLLMENT

Parent/Guardian
Your Name*

First NameLast Name
Please submit your email*
example@example.com
Area Code*   Phone Number*

Street Address*      City*   State*   Zip*

*

Please check person(s) to be contacted
Mother   Father   Both   Guardian*

*

*

*

*

*

*
Emergency Information

In case of an emergency, please list two other contacts, in the event we are unable to notify the parents/Legal guardians.
FIRST CONTACT
First Name Last Name Email Area Code Phone Number
SECOND CONTACT
First Name Last Name Email Area Code Phone Number
Alternate Drop Off
In case Parent/Guardian is Not Home

First Name   Last Name

Area Code   Phone Number

Email

Street Address   Address Line 2   City   State   Zip
Youth Information

Child #4 (OPTIONAL)
First Name   Last Name

Date of Birth

Grade

Tribal Status:
Tribal Member   D. Lineal   Lineal   Com. Resident
Youth Health

Known Allergies (Food, Bee Stings, ect...)

In the event of an accident/Major Injury and parent is not able to be contacted, I authorize a Recreation staff member to call 911 or seek immediate health care at preferred Hospital:   Name of Hospital   Name of Family Doctor   Contact #   Health Ins. Provider

MUST PROVIDE DOCTOR'S NOTE/VERIFCATION OF MEDICAL CONDITION

Asthma   Heart Problems   Seizures   Hearing Impaired   Other

IF OTHER please list more
AGREEMENT
By my signature I agree to allow the Department of Education and the Department of Recreation to provide educational and cultural services for my child and agree to participate in my child's educational progress. I also agree to provide any other information deemed necessary by the Department of Education and the Department of Recreation to further my child's academic and cultural knowledge and to allow authorization to release information and/or records from Santa Rosa Rancheria Social Service Department.

First Name* Last Name*
Signature*
Should be Empty:

Parent/Guardian