No-West Regional Special Services - Nor-West Regional Special ...

CHRISTOPHER J. MORABITO, MPA, CTRS
DIRECTOR
P.O. BOX 420
CRUGERS, NY 10521
914-737-4797
www.nor-west.org
________________________________________________________________
Special Recreation for Special Populations
PREP 2009 REGISTRATION FORM
Name:
Date of Birth: _____________ Age: ________
Home Phone: ________________________________________ Email: ___________________________________
Parent/Guardian Name:__________________________________________________________________________
Mailing Address: ______________________________________________________________________________
Number Street Town/City Zip
Cell Phone:_________________________________ Cell Phone :______________________________________
PARENT/GUARDIAN EMPLOYMENT INFORMATION:
Father: _________________________________ Phone:_________________________
Work Hrs: _____to____
Mother:_________________________________ Phone:__________________________ Work Hrs: _____ to____
EMERGENCY CONTACT PERSON: (Someone Nor-West will be able to contact in place of yourself)
1. Name:___________________________ Phone:_______________________ Relationship:__________________
2. Name:___________________________ Phone:_______________________ Relationship:__________________
FEE SCHEDULE: $ 99 DEPOSIT REQUIRED WITH APPLICATION
(non-refundable for reasons other than medical)
July 6 – July 31, 2009
Westchester Residents (no trans.) $ 99 ( ) paid in full
with round trip transportation $220 ( )
with one-way transportation $160 ( ) ___ to program, ___home from program
Putnam Residents (no trans.) $440 ( )
with round trip transportation $560 ( )
with one-way transportation $500 ( ) ___ to program, ___home from program
Check transportation pick-up/drop-off point that is best for you. This location is not guaranteed, but will be
used for transportation planning. Indicate first and second choice. (1, 2) Minimum of 2 people at each stop
Strang Middle School, Yorktown _________
Shoprite, Croton ______________________
Hen. Hud. HS, Montrose______________
A&P, Shrub Oak ______________________
Save-A-Lot Peekskill____________________
Park School, Ossining ___________________
Beach Shopping Ctr. @ Goodyear Tire _____
Parent Drop Off At Program 9:00am _______
Parent Pick Up At Program 3:00pm ________

NAME: ________________________________________________
HOSPITAL RELEASE AND PERMISSION - PLEASE COMPLETE
I give my permission in case of injury to take my son/daughter to the hospital for treatment, to include evaluation
for injuries, x-ray and any needed care.
SIGNATURE OF PARENT/GUARDIAN: _________________________________________ Date:______________
Hospitalization Insurance Co:__________________________________ ID#:_________________________________
Primary diagnosis: _________________________________________________________________________________
Allergies: _________________________________________________________________________________________
Medications (list all): _______________________________________________________________________________
Dietary restrictions: ________________________________________________________________________________
History of seizures: yes ______ no If yes, type:________________________________________________
PHOTO/VIDEO RELEASE (PLEASE CHECK ONE)
_____________ I hereby grant permission to Nor-West Regional Special Services to use my son/daughter’s
likeness, picture, voice, words or name in either television, radio, newspapers, magazines, brochures, flyers, and
other media, in any form, for the express purpose of advertising, fund-raising, or communication of the programs
and services of Nor-West.
_____________ I do not consent to the above photo release.
SIGNATURE OF PARENT/GUARDIAN:________________________________________ Date: ________________
*****NOR –WEST DOES NOT PROVIDE MEDICAL INSURANCE COVERAGE TO ITS PARTICIPANTS*****
Please send payment payable to:
Nor-West Regional Special Services
PO Box 420
Crugers, NY 10521
Deadline to register is May 15, 2009 on a first come basis with priority given to our catchment area residents
Out of area residents will be wait-listed and accepted after the deadline, as space permits
FOR OFFICE USE ONLY
DATE RCV’D ___________ ID # ______________ DEPOSIT CK # ______________ AMT RCV’D __________ DATE: ENTERED________
BALANCE DUE: ______________
DATE RCV’D __________
FINAL PAYMENT CK # ______________ AMT RCV’D ___________ DATE: ENTERED__________