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Youth Center Registration

  1. EMERGENCY CONTACT INFORMATION

  2. AUTHORIZED PICK UP

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

    Please click on all that apply.

  4. 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.

  5. DIETARY RESTRICTIONS AND ALLERGY INFORMATION

  6. PHOTOGRAPHIC RELEASE

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

  7. Consent*

  8. 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.

  9. Form Completed By:

  10. 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.

  11. Leave This Blank:

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