CHILD'S NAME: *

First Name

Last Name

PARENT/GUARDIAN'S NAME: *

First Name

Last Name

PARENT/GUARDIAN'S PHONE: *

(###)

###

####

Where will your child go after martial arts? *

Pick-Up

Full Day Class

Aftercare

If anyone other than yourself will be picking up your child, please add them below. (NOTE: Caregivers may be asked to provide photo ID.)

The following people listed below are authorized to pick up the above named child from the YMCA at Glen Cove Child Care:

AUTHORIZED PERSON:

First Name

Last Name

PHONE:

(###)

###

####

AUTHORIZED PERSON:

First Name

Last Name

PHONE:

(###)

###

####

AUTHORIZED PERSON:

First Name

Last Name

PHONE:

(###)

###

####