Ethics for Youth Registration

Ethics for Youth Registration

Registration for Brooklyn Ethical's Ethics for Youth Program. If you have any questions or concerns, please email community@bsec.org.
Caregiver Information
Primary Caregiver Full Name

First NameMiddle NameLast Name
Relationship to Child
Primary Caregiver Email
example@example.com
Primary Caregiver Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Caregiver Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Caregiver Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Second Caregiver Full Name (if available)

First NameMiddle NameLast Name
Second Caregiver Relationship to Child
Second Caregiver Email
example@example.com
Emergency Contacts and Authorized Pickup
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is your child allowed to leave by themselves at the end of the class?

Other
If an adult(s) is(are) picking them up, please list their names below:
Children Registration
Child information
Please share anything we should know about your child.
Permissions and Consents
Consent for supervised field trips and outings
Consent for workshops and special activities
Photo and video consent
Health, Allergy, and Medical Information
Does the child have any food allergies?
If yes, please list each food allergy and any known details
How severe is the allergy reaction?
Does the child use an emergency medication or auto-injector?
Please describe other health concerns, medical conditions, physical limitations, medications, and any emergency care instructions
Signature and Agreement
Parent/Caregiver Electronic Signature
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Registration Term, Scholarship, and Payment
Registration Term
If you applied for scholarship, select the status below. If you have not, selected N/A
If you have applied for scholarship and been approved, select "Scholarship in the term field below
Payment
prevnext( X )
Registration Fee
Program registration payment based on selected term and number of children. If you have been approved for scholarship, select the "Scholarship" on the Term pull down options.

$175.00 QuantityTerm

Total

$0.00
Should be Empty:

Ethics for Youth Registration

Caregiver Information

Emergency Contacts and Authorized Pickup

Children Registration

Permissions and Consents

Health, Allergy, and Medical Information

Signature and Agreement

Registration Term, Scholarship, and Payment

Payment*

Payment