Registration for Garden Explorers

Garden Explorers Fall Winter Enrollment Form
My child will need pick up from school (PS 321 only)
At program dismissal, my child will be met by (Full Name)
Phone number of person meeting child
Child's First Name
Child's Last Name
Child's Date of Birth (mm/dd/yyyy)
Current School
City
Address (required)
Apartment Number
State
Zip Code
Parent/Guardian First Name
Parent/Guardian Last Name
Home Phone
Mobile Phone (if no mobile phone, please re-enter home phone number here)
Email
Same address as child?
Parent/Guardian 2 First Name (if applicable)
Parent/Guardian 2 Last Name (if applicable
Same address as child?
Home Phone
Mobile Phone
Parent (2) Email
Emergency Contact Name (if unable to reach parent)
Emergency Contact Relationship
Emergency Contact Phone Number
Emergency Other Phone Number
Physician Name
Physician Phone Number
Special restrictions or anything else you would like us to know:
How did you learn of this class / course?
Release and Waiver of Liability: While participating in activities at the Old Stone House, each student is assumed to be voluntarily performing activities for which he/she assumes all risk, consequences, and potential liability. The undersigned hereby releases and hold harmless the Old Stone House and its agent or agents from any and all claims arising or resulting directly or indirectly from participation in activities at the Old Stone House.I authorize Old Stone House to take necessary action in case of emergency if I am unable to be reached.In addition, I authorize the Old Stone House to use photographs or recorded video in which my child appears in promotional literature, ads, displays or any format representing the program.
Today's Method of Payment. Please select Credit Card or Check from dropdown menu. Payment instructions will appear on next page after you click on "Send!" below.

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