Youth Registration Form - Hays Medical Center

Youth program you are registered for:

What school does your child attend?

Child Name:

Child Date of Birth:

Child Gender:

Mother/Guardian's Name:

Mother/Guardian's Cell Phone:

Mother/Guardian's Work Phone:

Mother/Guardian's Work Address:

Mother/Guardian's Address:

Mother/Guardian's City, State, Zip:

Mother/Guardian's Email:

Father/Guardian's Name:

Father/Guardian's Cell Phone:

Father/Guardian's Work Phone:

Father/Guardian's Work Address:

Father/Guardian's Address:

Father/Guardian's City, State, Zip:

Father/Guardian's Email:

Emergency Contact to be reached other than parent or guardian

Name:

Relationship

Daytime Phone

Evening Phone

Person(s) Responsible for taking child from activity:

1) Name:

1) Relationship:

1) Phone:

2) Name:

2) Relationship:

2) Phone:

3) Name:

3) Relationship:

3) Phone:

I Authorize my child(ren) to walk or drive to and from The Center: (required)

Hospital/Clinic: (required)

Physician's Name: (required)

Physician's Phone: (required)

Dentist's Name: (required)

Dentist's Phone: (required)

Insurance Company: (required)

Policy Number: (required)

Allergies/Medications/Special Health Considerations/Activity Limitations:

Other helpful/useful Information:

I authorize all medical and surgical treatment, X-Ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and or paramedics for my child and waive my right to informed consent of treatment. This waiver applies ONLY in the event that neither parent/guardian can be reached in case of an emergency:

I Agree to The Center / Hays Medical Center Terms and Conditions and Media Consent Form:

I AGREEI DO NOT AGREE

I have read The Center Youth Handbook

YESNO