HENRY STREET SETTLEMENT Division of Youth Services 301 Henry Street New York, NY 10002 (P) 212-254-3100 (F) 212-777-1445 Henry Street Settlement After-School and Camp Services Additional Pick-up/Emergency Contacts List (not required) Participants Name: _____________________________________________ Date of Birth: _______________ Name: Relationship: Phone Number: ( ) - Type: Work Cellphone □ □ □ □ Phone Number: ( ) - Type: Home Work Cellphone □ □ □ □ Is this person an Emergency Contact: Is this person authorized to pick up: YES NO YES NO □ □ □ □ Email Address: Language Spoken: English Spanish Mandarin Cantonese Other - Please Specify: ________________ □ □ □ □ □ Name: Relationship: Phone Number: ( ) - Type: Home Work Cellphone Other □ □ □ □ Phone Number: ( ) - Type: Home Work Cellphone Other □ □ □ □ Is this person an Emergency Contact: Is this person authorized to pick up: YES NO YES NO □ □ □ □ Email Address: Language Spoken: English Spanish Mandarin Cantonese Other - Please Specify: ________________ □ □ □ □ □ Name: Relationship: Phone Number: ( ) - Type: Home Work Cellphone Other □ □ □ □ Phone Number: ( ) - Type: Home Work Cellphone Other □ □ □ □ Is this person an Emergency Contact: Is this person authorized to pick up: YES NO YES NO □ □ □ □ Email Address: Language Spoken: English Spanish Mandarin Cantonese Other - Please Specify: ________________ □ □ □ □ □ CHILD MAY NOT BE PICKED UP BY RELATIONSHIP OF THE PERSON NOT ALLOWED Program Enrollment Packet 6 page
Henry Street Settlement After-School and Camp Services HENRY STREET SETTLEMENT Division of Youth Services 301 Henry Street New York, NY 10002 (P) 212-254-3100 (F) 212-777-1445 Additional Pick-up/Emergency Contacts List (not required) Participants Name: _____________________________________________ Date of Birth: _______________ Name: Relationship: Phone Number: ( ) - Type: □ □ Work □ Cellphone □ Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Is this person an Emergency Contact: □ YES □ NO Is this person authorized to pick up: □ YES □ NO Email Address: Language Spoken: □ English □ Spanish □ Mandarin □ Cantonese □ Other - Please Specify: ________________ Name: Relationship: Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Is this person an Emergency Contact: □ YES □ NO Is this person authorized to pick up: □ YES □ NO Email Address: Language Spoken: □ English □ Spanish □ Mandarin □ Cantonese □ Other - Please Specify: ________________ Name: Relationship: Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Is this person an Emergency Contact: □ YES □ NO Is this person authorized to pick up: □ YES □ NO Email Address: Language Spoken: □ English □ Spanish □ Mandarin □ Cantonese □ Other - Please Specify: ________________ CHILD MAY NOT BE PICKED UP BY RELATIONSHIP OF THE PERSON NOT ALLOWED Program Enrollment Packet page 6
FY18-Manhattan-Charter-School-2_Program-Application.docx