Youth Program Information Form

Use this online form to submit all the emergency and safety info for your child for our Youth Programs. You can also download a PDF version to print and send to ksantor@burlingtonvt.gov. Click here for the Medication Authorization Form

Youth Program Information Form

This form is valid for one calendar year (January 1- December 31) and covers any and all programs that your child participates in during that time. If any information changes throughout the year, please update it when registering for programs.
Child's Name*
First Last
Date of Birth*
Month
Day
Year
Age
Gender
Grade (fall of current year)
Name of First Parent/Guardian*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Second Parent/Guardian
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
The following people have permission to pick up my child:
Name
First Last
Relation
Phone
Name
First Last
Relation
PERMISSION FORM
Permissions below cover any and all programs that your child participates throughout the year. Please inform staff if there are changes related to a specific program.
I grant permission for my child to participate in all field trips. This includes any walking and/or bus field trips.*
- DO
- DO NOT
I grant permission for my child to watch a PG movie.*
- DO
- DO NOT
I grant permission for the City of Burlington or its agents to photograph or record my image or voice (or if the participant is a minor, my child’s image or voice), during recreation programs and activities, without payment or consideration. I understand that any such photographs or recordings will become the property of the City of Burlington.*
- DO
- DO NOT
I give permission for the BPRW staff to contact my child’s school personnel including principal, guidance counselor, teacher, or special educator, if needed, to develop a support plan.*
- DO
- DO NOT
I give permission to obtain my child’s immunization records*
- DO
- DO NOT
I give permission for my child to participate in swimming activities*
- DO
- DO NOT
I give permission for staff to apply sunscreen*
- DO
- DO NOT
I give permission for my child to walk/bike home on their own*
- DO
- DO NOT
I give permission for BPRW staff to contact my child’s physician/dentist or to seek emergency medical care in an emergency*
- DO
- DO NOT
MEDICAL INFORMATION
Check boxes that apply and please provide details below*
- NONE
- Food, bee, or other allergies
- Physical limitations
- Special dietary requirements
- Medication required
- Other special needs
- Child has an IEP, 504 Plan, or aid during school
Please provide details for info above
If medication needs to be administered during a program, please complete the Medication Administration Form
EMERGENCY CONTACT INFORMATION
Two contacts other than parents/guardians
Emergency Contact #1*
First Last
Relation*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact #2*
First Last
Relation*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Dentist
Phone
Child’s Physician
Phone
Form Submission
By submitting this form electronically, you agree that you have read, understood and provided accurate information.

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Click here for the Medication Authorization Form enjoyburlington.com/…/Youth-Registration-Form-2023-fillable.pdf

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Youth Program Information Form

Youth Program Information Form

The following people have permission to pick up my child:

PERMISSION FORM

MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION

Form Submission