CHILD'S NAME: *

First Name

Last Name

PARENT/GUARDIAN'S NAME: *

First Name

Last Name

PARENT/GUARDIAN'S PHONE: *

(###)

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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.

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:

(###)

###

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AUTHORIZED PERSON:

First Name

Last Name

PHONE:

(###)

###

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AUTHORIZED PERSON:

First Name

Last Name

PHONE:

(###)

###

####