Education Days Registration Form

Only those children enrolled in the program may attend education days on December 30 and/or January 2.
Your child should bring a bag lunch including a beverage and any utensils needed. Please note: there is no refrigeration or warming facilities provided.
If your child is enrolled and you must cancel for any reason, your registration fee is non-refundable unless a child on the waiting list can fill your space by the registration deadline. In the event the cancelled space is filled, a 50% processing fee will be deducted from your refund. All refund requests must be submitted in writing via email to: education@wcny.org. Please indicate Refund Request and the program name in the subject line. The Original Transaction will be refunded through the payment source. PLEASE NOTE: If a child is unable to attend a program and there is a current wait list, we will replace that child with the first person on the wait list. You may not make your own replacements if a child is unable to attend.

Please complete the following information (print legibly or type, please):

Child’s Full Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Birthdate*

Gender (check one)

MALE
FEMALE

Parent/Guardian Full Name*

First Last

Daytime Phone*

Please indicate the preferred contact person and phone number to call during Homeschool Day at WCNY.

Alt. Phone

Parent/Guardian Signature*

I hereby register my child for the above mentioned WCNY program. I further understand that I must give the WCNY Education staff a two-week written notice to cancel this registration and if I fail to supply the two-week written notice, I will be responsible for the full payment of the session.

Medical Information: Child’s Full Name*

First Last

Child's Physician Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Preferred Hospital*

Emergency Contacts/Authorized Pick Ups (other than Parent/Guardian):

Name*

First Last

Relationship*

Phone*

Name

First Last

Relationship

Phone

Will your child be bringing any medication to WCNY?*

Please note: your child must be able to administer the proper medication dosage her/himself. Otherwise parent/approved guardian must be present to do so.

List of Medication(s):

Does your child have any food allergies? Yes / No If yes, what:

Does your child have any special needs, including behavioral, emotional or physical? Please describe them below so that we can best support your child. The Associate Director of Education will contact you with any follow up questions.

Parent/Guardian Signature:*

I have provided WCNY with any pertinent information which may assist WCNY program staff in caring for my child including but not limited to allergies, disability or limiting conditions, or emotional, developmental, or behavioral challenges. I agree to notify the WCNY Education staff immediately in writing of any changes in address, phone numbers, emergency contacts, or inability to attend by the registration deadline.

I give consent to WCNY to use any photographs or video of my child for promotional or public relations purposes, including web site material and program advertising.*

How did you hear about our Homeschool Day? (Please check all that apply)*

WCNY Radio
WCNY TV
WCNY E-guide
Flyer/Brochure
Email/social media
Other

Help us to know how to reach other parents by answering the question below - thank you!

If other, please specify:

TV

Local Programs

Local Documentaries

National Programs

PBS KIDS