BYA Sports Program Application

BYA Sports Program Application

Sports Program/s Registering For:

SoccerTrackBasketballBoxing/Martial ArtsGolfBaseballOther

You select 'other' please provide a response below:

PARTICIPANT INFORMATION

First Name

Last Name

Drivers/ School/ State ID #

Address Line 1

Address Line 2

City

Country

State

Postal Code

Phone

Date of Birth (MM/DD/YYYY)

Are You/Your Child enrolled in Medi-Cal?

Gender

Ethnicity: Hispanic/Latino/a?

YesNo

Race: (Check all that apply)

Black/African AmericanAsianAmerican Indian/Alaskan NativeWhiteNative Hawaiian/Other Pacific IslanderOther or Multiracial

MEDICAL HISTORY AND COVERAGE

NAME OF FAMILY DOCTOR

Phone

HEALTH INSURANCE PROVIDER

INSURANCE ID #

HAS THE PARTICIPANT COMPLETED THE FOLLOWING?

Chicken Pox Shots

Mumps Shots

TB Test Shots

Tetanus Booster Shots

German Measles Shots

DOES THE PARTICIPANT HAVE

Asthma

Vision Problems

Hearing Problems

Speech Problems

DOES THE PARTICIPANT HAVE ANY OF THE FOLLOWING ALLERGIES?

Food

Insect Bites

Medications

Plants

Other Allergies not listed above, please specify

Special Health Needs

Adult(s) Living with Participant Contact Details

Parent/Guardian (Primary)

First Name

Last Name

Daytime Phone

Cell Phone

Email

Relationship with Participant

Adult(s) Living with Participant Contact Details

Parent/Guardian (Secondary)

First Name

Last Name

Daytime Phone

Cell Phone

Email

Relationship with Participant

EMERGENCY CONTACT

First Name

Last Name

Daytime Phone

Cell Phone

Email

Relationship with Participant

INCOME ELIGIBILITY

Please attach recent Bank Statement, Payroll Stub, Tax Return or Self-Certify to apply for services under BYA's Discounted Fee Schedule.

Check all that apply

Single Parent FamilyDisabledChronically HomelessHomeless/Couch SurfingPrevious or Current Foster YouthPregnant or ParentingEmployed or in Job Training?

Family Receives Public Assistance?

AFDC/TANF/Cal Works?

Cal FRESH (Food Stamps)?

Medi-Cal?

Social Security Income (SSI)?

Disability?

Unemployment?

Other, Self-Certify

HOUSEHOLD SIZE

INCOME LEVEL

How were you referred?

Please select a choice below

Social MediaFlyerBYA WebsiteFamily/FriendOther

You select 'other' please provide how you were referred below

Contact Information