Enrichment Registration

Basic information:

Personal:
Registration: For which semester are you registering?
    
For which class(es) are you registering?
    
Residence




Guardian Information




Emergency information:

Primary emergency contact

Personal


Secondary Emergency Contact

Personal


Health History:

Allergy/Medical Information





*Chronic Health Concerns (please check all that apply):




Authorization to Participate:

The student herein described has permission to engage in all activities in the program except as noted.

Consent

I am giving my child permission to sign himself/herself in and/or out of this program. My child is allowed travel to and from the program on his/her own without adult supervision:

Authorized Persons for Pick-up:

For the safety of your student, you will be asked to "sign-in" as well as provide the following information for anyone authorized to pick up your student for release or emergency. A proper form of identification:such as a driver's license, will be required to release a student. Program personnel will not release any student to anyone without proper authorization from the parent/s or guardian's and without proper identification. Please make sure you abide by this rule. There will be absolutely no exceptions.

Contacts

Contact 1




Contact 2




Contact 3




You may print this form and mail it in with your payment ($250 for 1 semester, $400 for both semesters per student) to:

Queensborough Community College
Attn: Susan Agin/Box Office
222-05 56th Avenue
Oakland Gardens, NY 11364

Once your registration form is received, a representative from our office will call you to confirm receipt. For additional information call: 718-631-6311.




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