After School Care Registration Form 2004 - 2005
Please print and complete form and mail to the address below:                                           

  Back to After School Care

Family YMCA at Tarrytown, 62 Main Street, Tarrytown, NY 10591  (914) 631-4807
 

Text Box: Child’s Name:                                                                                                              Date of Birth________________        Sex__________ Age _________________  Address_________________________________________________Apt                City__________________________________State______________Zip                Allergies:                                                                                                                         Text Box: List all persons permitted to remove your child from the program:                                Mother  Y or N       Father  Y or N  (Circle)   Name Relationship Phone #                                 *Your child will not be released to anyone else unless you notify the YMCA by phone or in writing.

 

 

 

 

Text Box: Start Date:                                         School/Grade                                                  What days will your child be attending the program? (Please Check) Mon                 Tue                  Wed                 Thurs                Fri                   

 


 

Name

Home Phone #

Work Phone #

Mother:
 

                                      

                                   

Father:
 

 

 

Guardian:
 

 

 

Text Box: Emergency Contacts: Persons to be notified in case of illness or accident.  This must be someone other than you.  We will try you first.   Name Relationship Phone #                                                                                                        Text Box: *Please read and next page*