Basic Information

Name of Child
Child Home Address

Medical Information

Does your child have any medical concerns, allergies, or physical limitations? Please list all:
If Parent 1 and/or Parent 2 are Essential Personnel (check all that apply):
What days would you like to register for?
Program begins at 7am.
Bay Shore Program ends at 5:00pm.  S. Huntington Program ends at 6:00pm.
Parent/Guardian 1
Parent/Guardian 1:
Parent/Gardian 2
Emergency Contact 1
Emergency Contact 1
Must include someone other than Parent/Guardian
Emergency Contact 2
Emergency Contact 2
Must include someone other than Parent/Guardian
Authorized Pick Up Information
Name #1
Must include adults other than Parent/Guardian. Will be asked to provide photo ID upon pickup.
Name #2
Unauthorized to Pick Up
Name #1
Name #2

I hereby authorize Northwell Health, through designated members of its medical/nursing staff, to examine and (as necessary) treat the individual named above, who is a minor and under my guardianship in the event of any accident, injury or illness. I understand and acknowledge that, whenever feasible, Northwell Health will try to contact me and obtain consent prior to providing such medical services. However, in an emergency, care may be provided without such consent. Only emergency medication will be administered. An Individual Health Care Plan and Medication Consent form must be filled out at the time of registration. I consent to allow my child to participate in all activities included in the program. In the event of a medical emergency, I allow my child to be transported by ambulance to the local hospital. I understand my child is expected to behave in a responsible and respectful manner, appropriate for their age. Also, if my child is ill or behaves in an unsafe manner, parents and/or guardians or authorized pick up must be available within one hour to pick up the child from the program. I understand that it is my responsibility to make arrangements for my child to be picked up no later than 6pm.

Please type your name
CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.