Step 1:

Summer Camp Enrollment Form

9 Children

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1: First Name *

Parent/Guardian 1: Last Name *

Parent/Guardian 1: Phone *

Parent/Guardian 1: Email *

Parent/Guardian 2: First Name

Parent/Guardian 2: Last Name

Parent/Guardian 2: Phone

Parent/Guardian 2: Email

CHILD 1 INFORMATION

Child 1: First Name *

Child 1: Last Name *

Child 1: Date of Birth *

Child 1: Gender *

Child 1: Phone

Child 1: Email

CHILD 2 INFORMATION

Child 2: First Name *

Child 2: Last Name *

Child 2: Date of Birth *

Child 2: Gender *

Child 2: Phone

Child 2: Email

CHILD 3 INFORMATION

Child 3: First Name *

Child 3: Last Name *

Child 3: Date of Birth *

Child 3: Gender *

Child 3: Phone

Child 3: Email

CHILD 4 INFORMATION

Child 4: First Name *

Child 4: Last Name *

Child 4: Date of Birth *

Child 4: Gender *

Child 4: Phone

Child 4: Email

CHILD 5 INFORMATION

Child 5: First Name *

Child 5: Last Name *

Child 5: Date of Birth *

Child 5: Gender *

Child 5: Phone

Child 5: Email

CHILD 6 INFORMATION

Child 6: First Name *

Child 6: Last Name *

Child 6: Date of Birth *

Child 6: Gender *

Child 6: Phone

Child 6: Email

CHILD 7 INFORMATION

Child 7: First Name *

Child 7: Last Name *

Child 7: Date of Birth *

Child 7: Gender *

Child 7: Phone

Child 7: Email *

CHILD 8 INFORMATION

Child 8: First Name *

Child 8: Last Name *

Child 8: Date of Birth *

Child 8: Gender *

Child 8: Phone

Child 8: Email

CHILD 9 INFORMATION

Child 9: First Name *

Child 9: Last Name *

Child 9: Date of Birth *

Child 9: Gender *

Child 9: Phone

Child 9: Email

EMERGENCY CONTACT INFORMATION

Full Name *

Phone Number *

Email

Relationship to Child(ren) *

MEDICAL INFORMATION

Does the camper have any medical conditions or allergies? *

Please Specify

Is the camper currently taking any medications? *

Please Specify

Any special accommodations or needs? *

Please Specify

Registration Payment *

6-Week Standard Registration Discounted | 9 Children

$7191

By checking the checkbox below, you are acknowledging that you have read, understood, and agreed to abide by the procedures, guidelines, and liability waiver of the NYCMC Summer Camp.

I agree to NYCMC Summer Camp Policy & Procedure Guidelines & Liability Waiver provided by the NYCMC. By providing my phone number, I agree to receive text messages from the New York City Muslim Center.

At NYCMC, we believe in the power of sports and physical activity to unite, inspire, and promote the overall well-being of our community.

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Step 1:

Summer Camp Enrollment Form

9 Children

90-20 191 Street, Hollis, NY 11423

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