PRINT FORM
Name _________________________________________________________________________________ Telephone # ( )_______________________ Last First MI
Address
_________________________________________________________________________________
Gender: M F Age _______
_________________________________________________________________________________________
Birthdate ______/ ______/ _______
City
State Zip Code
School _____________________________________________________ NYSP Returnee?: (please circle) Yes No If yes, how many years? _______
Parent/legal guardian_______________________________________ Telephone: Home ( ) ________________ Telephone: Work ( )___________________
Emergency Contact Name:
___________________________________________________________ Telephone: Home
( ) ___________________________
*Must be a different
person than parent/legal guardian*
Relationship of emergency contact to camper _______________________________________________ Telephone: Work ( )______________________
Address of emergency contact _______________________________________________________________________________
____________________________________________________________________________________________________
City
State
Zip
Code
I understand and consent that
a medical examination will be required before enrollment in NYSP and that the
host institution and/or NYSPF is authorized to
obtain medical care or treatment deemed necessary.
________________________________________________________
Parent/Guardian Signature Date Box
for Office Use Only!
