New Participant Registration Form

    Important: New participent registration. If you have already submitted this form, you don't need to submit it again, unless you want to update/change your information.

    Print and drop off completed form on first day of class.

    Parent/Guardian Information

    Student Information

    Program Option​
    School pick up is available for students attending
    Brooklyn Arbor,  P.S.17,  P.S.18,  P.S.84,  P.S.110,  P.S.132,  P.S.319, Williamsburg Northside School,  Success Academy Williamsburg

    Medical Information and Additional Needs

    Medical Form

    Please upload a copy of your child's most recent  Child and Adolescent Health Examination form with proof of up to date  immunizations
    Max file size: 20MB

    Sibling Registration

    Fill out this section ONLY if you plan for additional children to attend classes.
    School pick up is available for students attending
    Brooklyn Arbor,  P.S.17, P.S.18, P.S.84, P.S.110, P.S.132, P.S.319, 

    Program Option

    Medical Information and Additional Needs(Sibling)

    Sibling Medical Form

    Please upload a copy of your child's most recent  Child and Adolescent Health Examination form with proof of up to date  immunizations
    Max file size: 20MB

    Emergency Contact Information

    In the event of an emergency in which the parent/guardian(s) are unable to be contacted, this person(s) will be notified:

    Authorized Pick Up 

    Only the following authorized individual(s) and parent/guardian(s) listed below will be allowed to pick up the child.

    MEdical Consent , Liability and Activity Release Form

     Must be completed by all participants or by parents/guardians of participants under age 21.

    I understand that r3space activities for which this MEDICAL CONSENT AND LIABILITY AND ACTIVITY RELEASE FORM is being given is described as: Indoor and outdoor activities at r3space programs. I hereby consent to the participation of my child in r3space activities and programs. I understand that I have a duty to provide primary accident and medical insurance for my child and I declare that my child is covered by primary accident and medical insurance. I release and forever discharge, r3space and their employees, and other representatives from any and all, damages and causes of action either at law or in equity that I may have as a result my child’s participation in, attendance at, and travel to and from the activity. Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold harmless r3space, employees, and other representatives against loss from any and all present or future claims, demands, or actions in law or in equity that may hereafter be made or brought by me or my child, by anyone on behalf of me or my child, or by anyone else on their own behalf for damages or any other legal or, equitable remedy on account of any injury, illness, physical condition, inconvenience or loss sustained by me or my child during r3space program, activities or travel to and from it. 

    As the parent or guardian of the child named above, give consent for my child to attend r3space. As a parent/guardian, I understand that my child’s participation will include indoor and outdoor activities, as well as excitement in connection with the camp program. I acknowledge that injuries may occur as a result of the participation in r3space programs, and I accept that consequence.  I hereby authorize the r3space medical staff or other appropriate r3space personnel to provide first aid, emergency medical care, or if necessary, admission to an accredited hospital when such care is necessary for the treatment. If I the parent/guardian can not be contacted that the provided emergency contacts can be contacted. 

    I hereby acknowledge that I have read this consent, understand its contents, and have signed it on my own free accord and deed.

    Media Consent

    I hereby consent to the participation of my child/children in interviews, the use of quotes, taking of photographs, or other forms of media.

    Signatures