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Early Childhood and Family Program Registration

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Participant's Name:    Date: 

Address: 
 
City: 
State:    Zip Code: 

Home Telephone number: 
Mobile Telephone number: 
Can you receive text messages? Yes   No

Birth Date of Child:  Age of Child: 

Parent / Guardian Name(s): 

E-mail address: 

Please list all names and ages of people the participant lives with: 



Emergency Contact: 
Emergency Contact Relationship to Child: 
Emergency Contact Telephone: 

Please list any health concerns, limitations, chronic illness, enrolled in B-3: 



Please list all known allergies: 



Does your child use an Epi Pen? Yes   No
If yes, please explain 


Does your child use an inhaler? Yes   No
If yes, please explain 


Does your child take medication? Yes   No
If yes, please explain 


I give permission for my child to appear in any media coverage and social networking approved by Youth Affairs Yes   No

The following information needed for Youth Affairs grant funding.

Are you currently homeless? Yes   No    Is parent Hispanic? Yes   No


Youth's Racial Background (Please check all that apply):
American Indian / Alaskan Native Asian Black / African American
Native Hawaiian / Other Pacific Islander   Multiracial   Caucasian / White


Family Size:  (Number of people in your family)

Please check all that apply below:
Two Parent Step & Birth Parent   Single Parent (female)
Single Parent (male)   Grandparents   Relative / Guardian
DCF Guardianship   Foster Parent(s)   On Own
Joint Custody   Other    

Select one option that best applies to your household:
$14,000  $19,000  $24,000  $29,000  $34,000  $39,000  $44,000  $49,000
$54,000  $59,000  $64,000  $69,000  $74,000  $79,000  $84,000  $89,000

I give my child permission to participate in all programs and activities conducted by the New London Youth Affairs, including field trips. I am fully aware of the risks inherent and hereby release the New London Recreation Department, City of New London, its elected or appointed officials, or volunteers from any and all liability, claims and injuries which may be sustained by me or my minor children on account of his/her participation in said programs or associated activities and events. If I can not be reached in the case of an emergency, I hereby give my permission to the physician selected by the New London Recreation Department's authorized staff member to hospitalize secure proper treatment for and order injection and/or anesthesia and/or surgery for my child.

Parent / Guardian or Adult Signature 
By entering my name in this field, I provide an electronic signature of consent and agreement.


©2018 New London Youth Affairs - 120 Broad Street - New London CT 06320   -   860-442-4994