Play Based Bronx
9143630424
Infoplaybasedbronx@gmail.com
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Play Based Bronx
When are you looking to start?
Child’s name:
First Name
Middle Name
Last Name
Date of Birth:
Place of Birth:
Sex
Age when filling out this form
Guardian 1:
First & Last name:
Email
Employer
Phone Number
Guardian 2:
First & Last name:
Email
Employer
Phone Number
Does your child speak Spanish?
Yes
No
Do parents speak Spanish?
Yes
No
If parents are not at same address, who should we address correspondence to?
Emergency Contact
Name
Telephone
Street Address
City
Zip Code
Contact info of Doctor to be called in case of Emergency
Do you authorize to administer all necessary? Emergency and First Aid care for your child?
Yes
No
List any allergies your child has, or medical conditions, seizures, Asthma, handicap:
Does your child have any disability? (Y) (N) If yes, please specify:
New York Department of Health requires that all children are vaccinated for school entrance. Do you vaccinate your child?
Yes
No
I, hereby, authorize Play Based Bronx to provide care for my child.
I declare to the best of my knowledge that all the statements made in this application are true.
First & Last name (Guardian 1):
First & Last name (Guardian 2):
Date
Date
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