160 West 78 Street, New York, NY 10024 * 212.873.0490 * www.87afterschool.org
Registration Form Spring 2025
Separate form must be completed for each child attending 87 Afterschool
Child Information (attending 87 Afterschool Only)
Last Name: _________________________ First Name: ________________________ DOB _______
Grade: _______ Room# _________ Teacher Name: ________________________ Age:
Parent Information
Parent/Guardian (1): ________________________________________________________________
Home Address: _____________________________________________________________________
City, State: _____________________ Zip: __________ Home Phone: ______________________
Cell Phone: ___________________________ Email: _______________________________________
Occupation: ____________________________ Work Phone: _______________________________
Child lives with this parent _______________
Parent/Guardian (2): ________________________________________________________________
Home Address: _____________________________________________________________________
City, State: _____________________ Zip: __________ Home Phone: ______________________
Cell Phone: ___________________________ Email: _______________________________________
Occupation: ____________________________ Work Phone: _______________________________
Child lives with this parent _______________
Emergency Contact/Pick up Authorization Information
*Contacts will be called in case of an emergency, if a parent cannot be reached*
(1) Name: ______________________________________________________________________________
Relationship: ____________________________ Cell Phone: _________________________________
Authorized to pick up________________________