Today's Date 12/08/2016
*First Name
*Last Name
*Address: Street
Apt #
*City
*State
*Zip Code
*Home Phone Number
Cell Phone
*E-mail Address
*Relationship to child enrolled in program

Child Enrolled In Adventure Program

*Child's First Name
*Child's Last Name
Nickname
*Date of Birth MM/DD/YYYY
Is there anything you want education staff to know in order to meet your child's learning needs:

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

*First Name
*Last Name
(check if the info is the same as above)

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)

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:

How did you hear about the program? (select all that apply)

Email notification
NYBG website
From a Friend
Non-NYBG website
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I hereby authorize The New York Botanical Garden and/or parties designated by the Botanical Garden to use (for non-commercial purposes only) any images of me or my children photographed at The New York Botanical Garden. I grant permission to use such images in any medium in furtherance of the not-for-profit mission of The New York Botanical Garden, including but not limited to posting on the NYBG Web site, publication in the Garden News newsletter and other Garden print material, and inclusion on signage on and around Garden grounds, internal presentations, external public relations media requests, etc. I understand that if I have any questions regarding the use of such images by The New York Botanical Garden, I may contact the Communications Department at 718.817.8616.

Click here if you agree.