YOKE Summer Activities Registration

Which session (location) will your student be attending?*

Due to health department and state restriction, we are limited to 40 participants at this time. Students will need to be registered for each session separately. Please make sure you are selecting the correct date and location.

Student Name*

First Last

Middle School Name*

Please use full name of school

Grade

entering fall 2020

Parent/Guardian Name*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/ Guardian Phone*

Parent/Guardian Email*

Emergency Contact*

Preferably someone other than a parent/guardian who would be available in case of an emergency in the occurrence that the above parent/guardian can not be reached.

First Last

Emergency Contact Phone Number*

Has your middle school student, or any member of your household been in close contact with a confirmed case of COVID-19?*

Yes
No

Is your middle school student or anyone in your household experiencing a cough, shortness of breath, or sore throat?*

Yes
No

Has your middle school student or anyone in your household had a fever in the last 48 hours?*

Yes
No

Has your middle school student or anyone in your household had a new loss of taste or smell:*

Yes
No

Has your middles school student or anyone in your household had vomiting or diarrhea in the last 24 hours?*

Yes
No

Are there any other medical conditions, including allergies, that we need to be aware of - in case of emergencies*

Please indicate "none" if there are no other medical condition or allergies