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Our June Bugs Summer Program is full.
Child's First Name: *
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Child's Last Name: *
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Date of Birth: *
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Gender: *
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Address: *
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City: *
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State: *
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Zip: *
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Parent 1 Name *
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Work/Cell Number: *
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Parent 2 Name: *
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Work/ Cell Number: *
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Email: *
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Caregiver: *
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Phone: *
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Current School (if applicable): *
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Emergency Contacts and Phone: *
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Child's Physician and Phone: *
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Medical Info (Allergies and Medical Conditions): *
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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
Butterflies: Entering a 3s Program in the Fall (Week 1 & 2 are full)
The Dragonflies Group is now full
* The June Program Begins June 12. The first week has been pro-rated.
All fees are due by April 22, 2019

For questions, email us at summer@chelseadayschool.org or call at 212-675-8541.
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