City Of White Plains Youth Bureau White Plains Youth Bureau Babysitter'S Training Participation Form (Page 4 of 5) in pdf

City Of White Plains Youth Bureau White Plains Youth Bureau Babysitter'S Training Participation Form Page 4

CITY OF WHITE PLAINS YOUTH BUREAU

September 2013 - June 2014

DROP-IN PARTICIPATION RELEASE FORM

Parents: Initial those activities you give your child permission to participate in:

Teen Lounge Computer Room Fitness/Boxing Chess Open Gym

Performing Arts Van Transportation __X__Babysitters Training Program

Name of participant

Address Apartment #

City White Plains State NY Zip Code

Birth Date Age Sex Race _______School Grade

Parent/ Guardian Name

Parent Address (if different)

Child=s E-‐‑ M ail address

Parent=s E-‐‑ M ail address

Home Phone Parent=s Work Phone

Parent=s Cell Phone

Emergency Contact: Name Phone

I, as parent/ legal guardian authorize my child , to participate in the above initialed activities.

This release grants permission for my child to participate in such programs as well as transportation within the City of White

Plains as related to these program activities. Any trips taken outside the city limits will require special permission that will be

sent home in advance of the trip.

Parent/Guardian Signature Date

______________________________________________________________________________

For Youth Bureau use only: RecTrac # Activity Code(s) Date

___

City Of White Plains Youth Bureau White Plains Youth Bureau Babysitter'S Training Participation Form Page 4