Today's Date 09/30/2016

Child Enrolled In Adventure Program

*Child's First Name
*Child's Last Name
Nickname
Birth Date
Grade Entering In Fall 2014
In which camp(s) is your child enrolled? 1. Art in Nature: July 7-11
2. Forest Adventure: July 14-18
3. Wild Wetlands: July 21-25
4. Wildlife Discoveries: July 28-August 1
5. Art in Nature: August 4-8
6. Forest Adventure: August 11-15
7. Wild Wetlands: August 18-22
8. Wildlife Discoveries: August 24-29

Who will be the primary person responsible for communicating on behalf of the child?

*First Name
*Last Name
*Relationship to child enrolled in program
*Cell Phone
Other Contact Information:

Who will be the primary person responsible for pick-up and drop-off of the child/children?

(check if the info is the same as above)
*First Name
*Last Name
*Relationship to child enrolled in program
*Cell Phone
Other Contact Information:

Will there be a secondary person responsible for pick-up and drop-off of the child/children?

First Name
Last Name
Relationship to child enrolled in program
Cell Phone
Other Contact Information:
Notes about pick-up and drop-off you would like the education staff to know:
Is there anything you want education staff to know in order to meet your child's learning needs:
* Does this child suffer from any medical conditions or other problems that the Everett's Children Adventure Garden staff should be made aware?
Yes
No
If yes, please describe the medical condition and the appropriate attention NYBG staff should take to assist the child's needs.