...............................................................
Child's First Name: *
Your answer
Child's Last Name: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Your answer
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
Parent #1 Name *
Your answer
Work/Cell Number: *
Your answer
Email: *
Your answer
Parent #2 Name: *
Your answer
Work/ Cell Number: *
Your answer
Email: *
Your answer
Caregiver: *
Your answer
Phone: *
Your answer
Current School (if applicable): *
Your answer
Emergency Contacts and Phone: *
Your answer
Child's Physician and Phone: *
Your answer
Medical Info (Allergies and Medical Conditions): *
Your answer
Children new to Chelsea Day School must provide a Medical form and Immunization record before attending our program.
If none of the listed above can be reached, I give my permission for my child to be taken to NYU Medical Center, 550 First Avenue @ 33rd Street. I also give my permission for emergency treatment to be administered until a family member or my child's physician is contacted. *
Required
All fees are due by April 22, 2019
For any questions, please email us at summer@chelseadayschool.org or call at 212-675-8541
Submit
Never submit passwords through Google Forms.
This form was created inside of Chelsea Day School. Report Abuse - Terms of Service