NYAP Teen REACH Registration Form

NYAP Teen REACH Program

An after-school program students AND parents are excited about!
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
School attending*
Grade*
City of residence:*
County: *
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Completed Teen REACH Enrollment Form

If you have not completed this paperwork yet, that is okay. You can still submit this registration form and email the forms to your respective city's program director. You can find these emails and this blank form at www.nyap.org/TeenReach.
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Completed AAP Allergy & Anaphylaxis Emergency Plan

If you have not completed this paperwork yet, that is okay. You can still submit this registration form and email the forms to your respective city's program director. You can find these emails and this blank form at www.nyap.org/TeenReach.
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Completed Asthma Action Plan Form

If you have not completed this paperwork yet, that is okay. You can still submit this registration form and email the forms to your respective city's program director. You can find these emails and this blank form at www.nyap.org/TeenReach.
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Completed Authorization to Release School Records Form

If you have not completed this paperwork yet, that is okay. You can still submit this registration form and email the forms to your respective city's program director. You can find these emails and this blank form at www.nyap.org/TeenReach.
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Completed eCornerstone Informed Consent Guidelines Form

If you have not completed this paperwork yet, that is okay. You can still submit this registration form and email the forms to your respective city's program director. You can find these emails and this blank form at www.nyap.org/TeenReach.
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Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by NYAP during the selected camp. In exchange for the acceptance of said child’s candidacy by NYAP, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless NYAP and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against NYAP, including all teachers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all recreational activities.
Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to NYAP and its affiliates to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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