Kingsbridge Heights Community Center Teen Center 2017 Summer Registration Form
Please answer all required questions.
First name
Your answer
Last name
Your answer
Please select if you are a new or returning participant.
You are a returning participant if you were ever part of Teen, Tween or CDP
Please select which program you are registering for.
Required
Gender
Age
Your answer
Birthdate
MM
/
DD
/
YYYY
Home Address Line 1
Your answer
Home Address Line 2
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Participant's Cell Phone #
If you do not have a cell phone, enter N/A
Your answer
Participant's Email Address
If you do not have an email address, enter N/A
Your answer
Race/Ethnicity
Are you a U.S. Citizen?
If not, what's your country of origin:
If you're a U.S. citizen, enter N/A
Your answer
What is your current school?
Your answer
What is your grade level next year?
Do you receive or are eligible for:
Parent/Guardian Name
Your answer
Parent/Guardian Cell Phone Number
Your answer
Parent/Guardian Work Phone Number
Your answer
Parent/Guardian Home Phone Number
Your answer
Parent/Guardian Email Address
If you do not have an email address, please enter N/A
Your answer
Emergency Contact Name
Your answer
Emergency Contact Cell Phone Number
Your answer
Have you participated in any KHCC Program before?
If yes, which programs:
Your answer
Are you attending Summer School?
If yes, which subjects:
Your answer
Are you working this summer?
If yes, where?
Your answer
Do you have any special medical needs or allergies? If yes, please explain:
Your answer
Are you taking any medications? Please list.
Your answer
General Release and Trip Consent for Parent/Guardian
Required
Required
Required
Required
Required
Required
Required
Required
Participant Name
Your answer
Signature of Parent/Guardian (if under 18)
By signing below, I agree to all of the statements as stated above.
Your answer
Date
Your answer
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