Clone of YLC Orange Summer Registration Form

EMERGENCY CONTACTS AND AUTHORIZED PICK UP

Note: In case of an emergency, at least one parent, guardian or designated emergency contact person needs to be available to respond to the site within 15 minutes. Responding party should be authorized to make an emergency medical decision on behalf of the child.
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Person(s) Authorized to pick-up child from program (Other than Parent/Guardian)

Your child will not be released to any person not listed herein.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.

Do you authorize the City of Hialeah to transport the participant to and from program/events/field trips sponsored and/or approved by the Summer Program.
Date

MonthDayYear
Date

Please upload your documents below:
Please upload the following documents: Copy of Birth Certificate or Passport

Cancelof
Please upload the following documents: Proof of Residency-Utility Bill (Under Parents/Guardian Name)

If you are rented, please submit a notarized letter from your landlord or Lease Agreement
Cancelof
Please upload the following documents: Report Card from qualifying middle schools or acceptance letter from HEA, HMS, HFM, OR PRIVATE SCHOOL

Cancelof
Please upload the following documents: License

Cancelof
Please note that submitting a registration form does not confirm your enrollment in the program. To complete your registration, payment must be made at our main office. Additionally, if any required documents are missing, your registration will be returned for completion.
Date

MonthDayYear
Date
We're sorry, our program is only available to Miami-Dade County residents.
Should be Empty:

Child's Information