NuGen Enrollment Forms

Health and Medical Form
Child #1 & Physician Information
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies & Allergic Reaction
List all allergies and any action to be taken if your child has an allergic reaction.Provide necessary allergy medication, clearly labeled with your child's name and dosage.
Medical Conditions and Medication
List any medical condition or medical history requiring special attention, including currentmedications and regular dosage.
Activity Restrictions
Any specific activity to be encouraged or restricted?
Medical Release
In compliance with New York City Department of Health & Mental Hygiene requirements, no child can be enrolled without permission for emergency medical treatment. In case of emergency, I authorize the doctoror hospital to which my child is brought to perform any emergency procedure or operation, give treatment,
and administer an anesthetic to my child. I understand that I will be contacted if an emergency occurs.
Signature

Child #2 & Physician Information

Please press next at the bottom if you do not have a 2nd child enrolled.
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies & Allergic Reaction
List all allergies and any action to be taken if your child has an allergic reaction.Provide necessary allergy medication, clearly labeled with your child's name and dosage.
Medical Conditions and Medication
List any medical condition or medical history requiring special attention, including currentmedications and regular dosage.
Activity Restrictions
Any specific activity to be encouraged or restricted?
Medical Release
In compliance with New York City Department of Health & Mental Hygiene requirements, no child can be enrolled without permission for emergency medical treatment. In case of emergency, I authorize the doctoror hospital to which my child is brought to perform any emergency procedure or operation, give treatment,
and administer an anesthetic to my child. I understand that I will be contacted if an emergency occurs.
Signature

ACKNOWLEDGMENT OF RISK & PARTICIPATION CONSENT
Participation Consent
Child #1's Name

First NameLast Name
Child #2's Name

First NameLast Name
Parent/Guardian's Name

First NameLast Name
I, the undersigned parent or legal guardian, give permission for my child named above to participate in activities offered as part of the NuGen Kids Club afterschool program.

Program activities may include, but are not limited to: music and dance; soccer; basketball; theater and performing arts; media and creative activities; indoor and outdoor recreation; structured play; physical fitness and movement activities;
games and group activities; and other age-appropriate enrichment activities.
I understand that activities may change during the school year based on enrollment, staffing, instructor availability, facilities, weather, scheduling, and program needs.
Acknowledgment of Risk
I understand that participation in sports, recreation, dance, physical activity, and other program activities involves ordinary and inherent risks. These risks may include falls, collisions with other participants, contact with equipment, bumps,
bruises, cuts, sprains, strains, and other injuries that can occur during normal participation.

I understand that NuGen Kids Club staff will take reasonable precautions and follow applicable safety and supervision procedures; however, not every injury or accident associated with participation can be prevented. By signing this form,

I acknowledge these ordinary and inherent risks and voluntarily give permission for my child to participate.
By signing my name below, I acknowledge and certify that the information I have provided is accurate and complete to the best of my knowledge. I further acknowledge that I have read, understand, and agree to comply with all policies, terms, and conditions stated above. I understand that typing my name constitutes my electronic signature and indicates my consent and agreement.
Signature
Should be Empty: