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Youth Center Registration: 2019/2020 School Year

  1. Proof of age may be required*

  2. EMERGENCY CONTACT INFORMATION

  3. AUTHORIZED PICK UP

  4. I would like my child to be picked up from PS/IS 217 on:

    Please click on all that apply.

  5. Permission To Walk Home

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

  6. DIETARY RESTRICTIONS AND ALLERGY INFORMATION

  7. 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.

  8. PHOTOGRAPHIC RELEASE

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

  9. Consent*

  10. 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.

  11. Form Completed By:

  12. 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.

  13. Leave This Blank:

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