Early Childhood & 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 is 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: 

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 an option that best approximates your annual household income:
 $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.



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