New London Youth Affairs - Early Childhood Family Center

Early Childhood & Family Program Registration

To curb spamming of our form, your IP address has been automatically recorded; 98.81.24.230.

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.