Nurturing in the Neighborhood Registration
March 23, 24, 30, 31 | 10 a.m.- 12 p.m.
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Email *
Parent/guardian first and last name *
Home address *
Phone number *
Child # 1 Information
Child's first and last name
Child's date of birth *
MM
/
DD
/
YYYY
Please list any known allergies *
Child # 2 information
Child's first and last name
Child's date of birth
MM
/
DD
/
YYYY
Please list any known allergies
Sessions you plan on attending *attend all four and win a prize!* *
Required
Image release information
I grant Niagara University permission to use my or my child's image, voice, and likeness in any and all forms of media, including but not limited to print, radio, television, and the Internet. This permission includes the use of my or my child's name, portrait or picture as protected by the New York Civil Rights law. I understand that I will not be compensated for this use. I acknowledge that I am at least 18 years of age, or that this release has also been signed by my parent or guardian. *
Areas of interest or concern regarding child development or health or any additional information you would like to share.
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