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Youth Center Summer 2019 Registration & Release Form

  1. Overview

    Registration for the Youth Center summer "drop-in" program will be ongoing until spaces are filled. All guardians of participants who currently attend the program are required to submit a new summer registration form for their child. New identification cards will be issued once your application has been reviewed and approved. We will contact you directly if there are any issues. Please note that all fields must be completed, electronically signed and submitted for EACH child attending for the summer. The summer program will begin on Thursday June 27th and end on Friday, August 31st with operating hours 8 AM -7 PM, Monday- Friday. The center will be closed Thursday, July 4th. The summer program is available for children ages 7- 18 years of age. No exceptions will be made. The schedule for summer activities will be sent to all registered families beginning June 14th. Please call 212-832-4559 if you have any issues completing this form.

  2. Other persons authorized to pick up my child from the Youth Center Program:

  3. Activities are provided for participants of all abilities. If there is a need for reasonable modification, please answer YES below and speak to the Youth Center Director prior to the start of the summer program.

  4. Photographic and Media Release*

    The photographic release allows your child to be photographed and/ or videotaped for promotional uses for the Youth Center ONLY.

  5. Gifts*

    By checking the "I agree" box below, you agree and acknowledge that the Youth Center is a State entity and that State officers and employees are prohibited from accepting gifts of more than $15 from individuals and entities that do business with the State.

  6. Physical Activity*

    By checking the “I agree” box, you agree and acknowledge that activities and/or programs which involve swimming and physical activity/exercise associated with participation in any and all such youth programs and/or “drop in centers” may involve risk of serious injury. It is recommended that, prior to participation, any participant that engages in a program of physical exercise should do so only after consulting with a physician.

  7. Permission to walk home

    I hereby attest that my child is in the fifth grade (or above) and I give my child permission to walk home from the Youth Center.

  8. Form Completed By:

  9. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  10. Leave This Blank:

  11. This field is not part of the form submission.