...............................................................
Email address *
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
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
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
Butterflies
Our Butterflies group is currently at capacity. If you would like to be added to our waitlist email us at summer@chelseadayschool.org.
Grasshoppers (4s)
Dragonflies: (5-7)
* The June Program Begins June 13. The first week has been pro-rated.
All fees are due by April 9, 2018

For questions, email us at summer@chelseadayschool.org or call at 212-675-8541.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Chelsea Day School. Report Abuse - Terms of Service - Additional Terms