# Youth program registration form

Source: https://backpr.com/resources/templates/youth-program-registration-form. Last updated: 2026-10-19.

An all-in-one registration form for camps, after-school programs and classes: child and parent details, emergency contacts, pickup, health and payment.

Free download: PDF https://backpr.com/media/templates/backpr-youth-program-registration-form.pdf · Word https://backpr.com/media/templates/backpr-youth-program-registration-form.docx · Spanish PDF https://backpr.com/media/templates/backpr-youth-program-registration-form-es.pdf

> Please fill out one form for each child.

**Program**
- Program name: ______
- Session, weeks or days attending: ______
- Start date: ______

**Child**
- Full name: ______
- Name they go by: ______
- Date of birth: ______
- Grade in fall 20__: ______
- School: ______
- Language spoken at home: ______

**Parent or guardian 1**
- Name: ______
- Relationship to child: ______
- Cell phone: ______
- Email: ______
- Address: ______

**Parent or guardian 2**
- Name: ______
- Relationship to child: ______
- Cell phone: ______
- Email: ______
- Address (if different): ______

**Emergency contacts (other than parents)**
An emergency contact can pick up your child only if they're also listed under authorized pickup.
- Name, relationship, phone: ______
- Name, relationship, phone: ______

**Authorized pickup (other than parents or guardians)**
- Name, relationship, phone: ______
- Name, relationship, phone: ______
- Name, relationship, phone: ______
- Anyone who may NOT pick up this child (if it's a parent or legal guardian, attach a copy of the court order; without one, we may not be able to refuse pickup): ______

**Health**
- Allergies (and how serious): ______
- Medications (note any that staff must give during the program): ______
- Medical conditions staff should know about: ______
- Doctor's name and phone: ______
- Health insurance company and policy or member ID: ______

**Permissions**
Check each one you agree to. Leave a box blank to say no. If we give you a separate photo release, your answers there are the ones we'll follow.
- [ ] The program may use photos and video of my child in newsletters and reports
- [ ] The program may use photos and video of my child on its website and social media
- [ ] My child may go on field trips
- [ ] My child may swim (staff may give a swim test first)
- [ ] Staff may apply sunscreen and bug spray
- Swimming ability (non-swimmer, beginner, intermediate or strong swimmer): ______

**Payment**
Need help paying? Ask us for our separate scholarship application.
- Program fee: ______
- Deposit paid: ______
- Payment plan (dates and amounts): ______

**Agreement**
In an emergency, staff will call 911 if needed and contact me as soon as they can. If they can't reach me, I authorize program staff to get emergency medical care for my child, including ambulance transport and treatment by a doctor or hospital, and to share this form with the medical staff who treat my child.
- Parent or guardian's printed name: ______
- I have received, read and agree to the program's policies, including the refund policy, and I give the emergency care consent in this section. Parent or guardian signature: ______
- Date: ______

### How to use it
- Ask only for what you'll use. Every extra question slows families down and is more data to protect.
- Collect health details, authorized pickup and emergency contacts before the first day, not at drop-off.
- Keep signed forms where staff can reach them during the program, and lock up the rest.
- Check your state's licensing rules for any forms or fields they require.

**What should a youth program registration form include?**
Child and parent details, emergency contacts, authorized pickup, health information, permissions, payment and a signed agreement to your policies. This template covers each one.

**Do we need a separate medical form?**
Many programs use one: it gives staff a single page with allergies, medications and emergency care consent. Use our medical and allergy form if you need more detail than the registration form asks for.

Free to use and change, but not legal or medical advice. Check your state's licensing rules and your insurer's requirements, and have a lawyer review any consent or waiver language.