Youth Program Enrollment Form

This form is used to enroll children or teenagers in official public-sector youth development programs, camps, or extracurricular initiatives. Please fill in all necessary information to ensure accurate registration and proper care of enrolled participants.

Participant Information

First Name: {firstName}

Last Name: {lastName}

Date of Birth: {dateOfBirth}

Age: {age}

Gender: {gender}

Parent/Guardian Information

Full Name: {guardianName}

Relationship to Participant: {relationship}

Phone Number: {guardianPhone}

Email Address: {guardianEmail}

Home Address: {guardianAddress}

Emergency Contact

Full Name: {emergencyContactName}

Relationship: {emergencyContactRelationship}

Phone Number: {emergencyContactPhone}

Medical Information

Known Allergies: {allergies}

Medications: {medications}

Special Needs or Conditions: {specialNeeds}

{#hasInsurance}

Health Insurance Details

Insurance Provider: {insuranceProvider}

Policy Number: {policyNumber}

{/hasInsurance}

{^hasInsurance}

Notice: The participant does not have health insurance coverage on file at this time.

{/hasInsurance}

Program Details

Program Name: {programName}

Program Location: {programLocation}

Start Date: {startDate}

End Date: {endDate}

Authorized Pickup Persons

{#pickupPersons}

• {name}: Relationship: {relationship}, Phone: {phone}

{/pickupPersons}

Previous Participation History

{#previousPrograms}

• {programName} - Attended in {year}

{/previousPrograms}

Permissions and Agreements

I give permission for my child to participate in the selected youth program.

I authorize emergency medical treatment for my child if needed.

I allow the use of photographs of my child for promotional and documentation purposes.

Signature

Signature of Parent/Guardian: ___________________________

Date: {signatureDate}