New City After School Registration If you would like to sign your child up to attend New City After School, please fill out the form below. Once your registration is received we will contact you to confirm by phone. Once we've confirmed your child's enrollment your registration will be completed. Child's Name* First Last Address* Street Address City ZIP Code Child's Birthday* Child's Grade:*What school does your child attend?*Other siblings registering for New City Afterschool:Parent/Guardian 1* First Last Parent 1 phone:*Parent/Guardian 2: First Last Parent 2 phone:Parent email:*Will be used to notify you of cancellations, policy changes and other important information pertaining to New City Afterschool. Emergency Contact and Phone Number*Child's Demographic InformationGender Male Female Residence Farm Rural or town <10,000 Town 10,000 - 50,0000 Suburb >50,000 City >50,000 Ethnicity (optional, Select one) Not Hispanic Hispanic Race (optional, select all that apply) Asian Black White American Indian Hawaiian/Pacific Islander Military FamilyMilitary families are those that have immediate family member (parent/guardian; step-parent; sibling) regardless of branch. Yes (fill in status and branch below) No (leave blank status and branch) Status Active Reserve Retired BranchHealth InformationAllergies*Please list any known allergiesImmunizations (check immunizations you child has received) Tetanus Polio MMR Hepatitis B MedicationsMedicationPurpose of MedicationDosageAdminister When Health Insurance Company*Policy Number*WaiverI authorize my child to...* Participate in any events on or off site with New City Neighbors Ride in any vehicle driven by a New City Neighbors staff member or volunteer Receive emergency medical care with the consent of New City Neighbors; I understand I will be responsible for any medical fees incurred Have their picture taken by New City Neighbors and used in publications and other materials by NCN and its partners Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.
