Office of Youth Services
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REGISTRATION FORM
Applicant’s Name: __________________________,__________________________________________________
(Last Name) (First) (Middle)
Home Address: __________________________________________________________________
Gender: Male Female Age: _____ Date of Birth: ________________________
School: ______________________________ Grade: ____________ SASID#_________________
Family Size: ____ Family Unit (check one): Parent Parents Guardian
Parent/Guardian Name: ________________________,___________________________________
(Last Name)
(First)
Phone: __________________ Work: ___________________ Cellular: _______________________
Currently Employed: Yes or No Employer Name & Address:__________________________
I give permission for my child to walk home after BYC each day. Yes or No
Emergency Contact: Please list below person(s) authorized to pick your child up at the end of the
program day or who we may contact in the event of an emergency:
Name: ________________ Relationship: _________ Email: _____________________ Cell: ___________________
Name: ________________ Relationship: _________ Email: _____________________ Cell: ___________________
Family Health Care: Physician’s Name: _______________________Phone #: _________________
Primary Insurance Carrier: _________________ Secondary Insurance Carrier: _________________
My child has the following medical conditions:____________________________________________
Will any of these conditions hinder his/her ability to fully participate? Yes or No
If yes, please explain: ______________________________________________________________________________
List allergies, if any: _______________________________________________________________
In signing this form I certify that my child is a resident of Bridgeport. I understand I am registering my child for a low cost
subsidized program that require his/her participation in the program and that unless an unforeseen emergency
arises or special consideration is made, I agree to pick my child up at the end of the program day and no earlier.
I further agree to all the terms and conditions set forth above including the Lighthouse Policy located on the reverse. I further
agree my child’s academic records and photos for studies on the impact of after school programs on student achievement,
as well as publications, project videos and fund solicitation. I give permission for my child to receive emergency medical
attention and participate in trips while attending BYC. After School membership fee is $75.00. Summer membership fee
is $50.00. Additional $25.00 deposit is required which may be applied to the fee due depending on where you fall
on the sliding scale. No child will be turned away based on ability to pay.
(Please see reverse side for policy.)
Parent or Guardian Signature: ________________________________ Date: ______________
After School 2020/2021
Summer 2020
Both
Start Date:
