Parent or guardian information

First Name

Last Name

Describe your relationship to the student.

ParentGuardianOther

Phone Number

Parent or guardian home address

Street

City

State

ZIP Code

Participant information

First Name

Last Name

Phone Number

Birthdate

Participant's home address

Street

City

State

ZIP Code

Emergency contact details

Enter your emergency contact's first and last name.

What is their email address?

What is their phone number?

Medical information

Allergies (choose yes or no)

If you answered yes to any of the above allergies, please describe:

Current medications

Please use the "Add another medication" hyperlink to add each additional medications.

Medication Name:

Dosage amount/times:

Any information about your child that we should know?

Other information

Dietary restrictions:

Any information about your child that we should know?

EMERGENCY AUTHORIZATION

In the case of a medical emergency involving my child, I hereby give permission to the full-time staff of City Parks Foundation to act on my behalf and on behalf of my child in the event that I cannot be reached. I understand and give my permission to the City Parks Foundation staff to secure proper treatment for my child which may include calling 911, engaging with emergency medical personnel, and hospitalization, if necessary.

Agree

Consent and authorizations

I have reviewed and agree to the liability waiver.

Yes

Media/Photography Release Form:

I hereby agree to allow my child for whom I am the legal guardian, named above, to be interviewed and/or photographed and/or videotaped for promotional or news documents about City Parks Foundation’s free programs in parks.

I understand that I will not own rights to the resulting text, photography or video, or any benefits derived therefrom. I agree to the use of my daughter’s/son’s/legal guardian’s image and/or voice by City Parks Foundation or media companies discussing City Parks Foundation programs and waive rights to fees associated with such use. (Choosing no will also opt-out of Section 3, “Use and Materials Release,” in the liability waiver.)

YesNo

Media/Photography Release Form:

I hereby agree to be interviewed and/or photographed and/or videotaped for promotional or news documents about City Parks Foundation’s free programs in parks.

I understand that I will not own rights to the resulting text, photography or video, or any benefits derived therefrom. I agree to the use of my image and/or voice by City Parks Foundation or media companies discussing City Parks Foundation programs and waive rights to fees associated with such use.

(Choosing no will also opt-out of Section 3, “Use and Materials Release,” in the liability waiver.)

YesNo

Are you legally authorized to work in the United States?

YesNo

By submitting this application, I hereby give permission for my child, named above, to participate in CityParks Learn programs. I understand that this program includes field trips to sites other than the daily meeting sites, may include group and community service activities and that I will be provided with advanced notice of each trip location and timing. I give permission for my child to be transported in vehicles driven by trained, licensed and insured City Parks Foundation employees as well as to travel via subway and bus with the program manager and staff members as part of the program curriculum.

Pre-K	Kindergarten
1st	2nd
3rd	4th
5th	6th
7th	8th
9th	10th
11th	12th
None of these

	Yes	No
Seizures
Diabetes
Physical Disability
Chronic Illness
Asthma

	Yes	No
Insect Stings
Penicillin
Other medications

City Parks Foundation Learn Program Application