Child Care Programs Registration Form 
Your child can not attend until you have received email
* or telephone confirmation of registration * 
Parent/Guardian #1 Information
* First Name 
* Last Name 
* Relationship 
* Email 
* Address 
* City 
* State 
* Zip 
* Cell Phone 
  Home Phone 
  Work Phone 


Parent/Guardian #2 Information
  First Name   Last Name 
  Relationship    Email 
  Address   City 
  State   Zip 
  Cell Phone 
  Home Phone 
  Work Phone 


Other Information
* Are there any custody issues/orders
of protection in place concerning your
child that we should be aware of? 
  If yes, please explain and
submit a copy of the court order 


Emergency Contacts Other Than Listed Above
     
Contact #1  
* First Name 
* Last Name 
  Relationship  * Phone #1 
  Phone #2 
     
Contact #2  
* First Name 
* Last Name 
  Relationship  * Phone #1 
  Phone #2 
     
Physician  
* Physician 
* Address 
* City 
* Phone 


Participant/Parent/Guardian Release
     
I give my child(ren) my permission to participate in all activities offered. If attempts to contact me at the above listed phone #’s are unsuccessful, I authorize and give my consent for any emergency medical, surgical or dental treatment for my child(ren) anywhere/anytime should it be deemed advisable by a qualified medical Doctor or Dentist, and the prompt attention/treatment in an emergency. I authorize the North Shore Youth Council to take all necessary steps to insure my child(ren)’s health & safety in case of an emergency and to administer any needed medications. In case of accident or injury I will not hold the North Shore Youth Council, or its employees or volunteers responsible. I understand and assume all risks that may occur during my child(ren)’s participation in these programs. I understand that should any injury occur to my child(ren) at the program, I will be responsible for all medical treatment and other costs through my medical insurance policy and/or personal finances.  
* Parent/Guardian 
Signature 
* Date 


Enrollment Agreement
     
• I understand that I am enrolling my child for the 2017- 2018 school year.

• I understand that the program is open according to the official school calendar of the respective school district and it is my responsibility to check with the site supervisors for information on hours of operation for early dismissals, delayed openings, parent/teacher conferences, etc.

• I understand that I am responsible for payment of appropriate fees when due, and, when late, the appropriate late fees.

• I understand I must give 30 days written notice prior to withdrawal from the program, during which time I will be responsible for payment of the appropriate fees.

• I understand that in the event of any absences during program hours, I will be responsible for fees for time reserved, not actual time spent at the program.

• I understand that if a medical emergency arises, the program staff will first attempt to contact me. If I cannot be reached, the staff will contact my child's doctor as listed on the emergency contact section. If the emergency is such that immediate hospital attention is necessary, an ambulance or emergency vehicle may take my child to the hospital.

• I understand that North Shore Youth Council staff will not administer/dispense any medication. I understand that only basic first aid will be available (washing, band-aids, icepacks).

• I agree to adhere to the stated policies and procedures of the program and give my child(ren) permission to participate fully in this program.
  
* Parent/Guardian 
Signature 
* Date 


Registered Children
  
To register your child(ren), please click the Add a Child button.
 



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We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.

Contact Us: North Shore Youth Council •• P.O. Box 1286 •• Rocky Point, NY 11778 •• 631-744-0207 •• www.nsyc.com

©2018 SofterWare, Inc. v.2018.01.02-C