REGISTRATION – Summer Camp in Brooklyn Heights

Name *

First

Last

Date of Birth

Name of School of Attendance

Name of Parent/Guardian *

First

Last

Email *

Phone *

Please specify an emergency contact OTHER than the name specified in the Parent/Guardian Info above.

Name of Emergency Contact *

First

Last

Phone *

Any Food Allergies? *

Does the Child have an IEP *

Comments – Please specify any food allergies / IEPs / Other concerns you may have

If You Are Registering More than One Child, Please Enter Their Name and Age Below