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Summer Enrichment Program at Rio Bend 2023
YMCA will provide a summer enrichment program at Rio Bend. Program will begin on June 5, 2023 and will end on August 4, 2023. Program hours are Monday - Thursday from 1pm-5pm.
*Please fill out one form per child.*
For more information please reach out to
christina.santibanez@ymcahouston.org
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* Indicates required question
Child's First Name
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Your answer
Child's Last Name
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Your answer
Student ID # (Lunch Number)
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Your answer
Child's Date of Birth
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MM
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DD
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YYYY
Child's Home Address, City, Zip code
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Your answer
Gender
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Female
Male
Other:
Ethnicity
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Your answer
Child's T-Shirt Size
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Your answer
Name of school child attends
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Your answer
Please list any concerns and/or needs
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Your answer
If your child requires any special accommodations, please describe below:
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Your answer
Name of parent or legal guardian
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Your answer
Parent/Guardian Date of Birth
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MM
/
DD
/
YYYY
Primary Phone Number
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Your answer
Secondary Phone Number
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Your answer
Parent's Email
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Your answer
Name of 2nd adult authorized to pick up child and be contracted in case of emergency
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Your answer
Phone Number of 2nd adult
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Your answer
Check next to Yes or No for the statements below:
I consent for my child to be transported and supervise by the YMCA staff.
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Yes
No
I consent for my child to participate in satisfaction and outcome surveys
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Yes
No
I consent for my child to participate in water activities
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Yes
No
I consent for my child to be photographed and/or videotaped while participating in the program
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Yes
No
My child has permission to ride a bus, bike, or walk home from program
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Yes
No
How many adults ages 18-64 live in the household
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4
other
How many seniors ages 65+ live in the household?
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0
1
2
3
4
Other
How many infants ages 0-2 live in the household?
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0
1
2
3
4
Other
How many toddlers ages 3-4 live in the household?
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0
1
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4
other
How many Youth ages 5-17 live your household?
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0
1
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Other
What is your current total household income?
*
under $10,000
$10,000 -$25,000
$25,000 - $40,000
Over $40,000
Signature
*
Your answer
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