OSH Winter Afterschool - The Old Stone House in Brooklyn

Student Name*

First Last

School*

Grade*

Select grade from dropdown.

Date of Birth*

I am registering for the following session:*

Thurs, 12/3 - 2/25 2:30 - 4:15

To request LIVE DROP-IN SESSIONS ONLY, write your request in the COMMENT field below.

My child has the following activity or medical restrictions. Please elaborate so that we may better meet your child's needs.

Parent Name

First Last

Parent Cell #*

Email*

Address*

Street Address City State ZIP Code

Emergency Contact*

First Last

Please provide a contact other than the parent listed above.

Relationship to student*

Emergency Cell #

Please tell us how you learned of this OSH program:

Please feel free to share any other comments you may have. Let us know if you are interested in LIVE SESSIONS ONLY.

Payment for live sessions is required at drop-off. Cash or checks only.

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 holds harmless the Old Stone House and its agent or agents from any and all claims arising or resulting directly or indirectly from participation in the program. I authorize the 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, as well as art my child produces, in promotional literature, ads, displays, website or any format representing the activities.*

I agree to Waiver

The fee for full participation is $300; $35/day for LIVE sessions. Please let us know how you plan to pay.*

Check
Cash

I am interested in financial aid

Yes

An application will be emailed to you.

You will receive an email confirmation upon successful registration. Please contact us at education@theoldstonehouse.org if you do not.

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Comments

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Release and Waiver of Liability

You will receive an email confirmation upon successful registration. Please contact us at education@theoldstonehouse.org if you do not.

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