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. Step 1 of 4 25% Child's Name* First Last Address* Street Address City ZIP Code Child's Birthday* Date Format: MM slash DD slash YYYY Child's Grade:*Must be in 2nd to 5th grade for Fall Session. 1st graders may begin attending for Winter Session. 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*Program InformationI would like to sign my child up for the following sessions* Select All Fall Session: Tuesdays & Thursdays October 1- December 19 (No program Oct 31-Nov 7 & Nov 28) Winter Session: Tuesdays & Thursdays January 7-March 19 (No program January 14-16) Spring Session: Tuesdays & Thursdays March 24- May 14 (No program April 2-9) Is your child enrolled in LOOP or another after school activity that meets the same days as New City Afterschool?*Preference may be given to students not involved in other programs. It is the parent's responsibility communicate with other programs if attending New City Afterschool will affect attendance of another program. Yes No If yes, what other program is your child enrolled in? 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 Branch Health 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* Pick Up/ Walk Home AuthorizationChild's Name* First Last Authorization to pick up*The following people have permission to pick up this child. (Please include all parents, guardians and emergency contacts, even if previously listed in this form. Even if your child usually rides the NCN van, this list must include all people who may pick up your child in the event of appointments, sickness, etc. We do check IDs.)Name (First and Last)Relationship to ChildPhone number Permission to Walk Home*I give permission for my child to walk home each day at the end of the program.YesNoParent or Guardian Signature*By entering your name you are authorizing what you stated above concerning pick up authorization and permission to walk home. First Last
