Additional Child Enrollment Form – Spokane North East Youth Center

NEYC Additional Child Information Form

This field is for validation purposes and should be left unchanged.

Child Information

Child's Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Medical Insurance Carrier Name

Group Number

ID Number

Hospital Preference(Required)

Date of Last Physical Exam(Required)

Date of Last Dental Exam(Required)

Doctor Name(Required)

Doctor Phone(Required)

Doctor Address(Required)

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

Dentist Name(Required)

Dentist Phone(Required)

Dentist Address(Required)

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

Known Medical Conditions(Required)

Yes

Condition Name (if applicable)

Current Medications(Required)

Yes

Medication Name (if applicable)

Known Allergies(Required)

Yes

Allergy Name (if applicable)

Special Dietary Needs(Required)

Yes

Please Explain (if applicable)

Child's Immunization Records(Required)

Please upload a complete copy of your child's immunization records. You may be able to access your child's records through: myirmobile.com or request a childcare copy of your child's immunization records from your child's PCP.

Max. file size: 60 MB.

Name of Signer(Required)

First Last

Signature(Required)

NEYC Additional Child Information Form

Child Information

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NEYC Additional Child Information Form

Child Information

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