Recreational Program Registration Form

To register, please take the time to fill out the information below.

Please indicate the program you are registering for:

Child's First Name

Child's Last Name

Gender

Male

Female

Age

Grade

School

Address

Town

State

Zip

Race

Parent/Guardian Name(s)

Phone:

Address: If same as above leave blank

Town

Alternate Phone (cell or work): If you are unavailable during the program please list an emergency contact below:

Emergency Contact

Phone:

Medical Information

Does your child have any medical condition that may impair his/her ability to participate in recreational activities (including exercise)? If yes, please explain. If no, please write N/A.

Does your child have any food allergies? If so, please list. If no, please write N/A.

OtherInformation

Please list all names of individuals Patchogue-Medford Youth & Community Services, Inc has permission to release your child to:

Name

Relationship

RECREATIONAL PROGRAMS

PROGRAMAS RECREACIONALES

Recreational programs are provided to school aged children within the Patchogue Medford School district to provide healthy after-school activities to keep them active and engaged socially in a supportive and safe environment. Activities include arts & crafts, cooking, guitar lessons, acting, dance, yoga, home work club and a drop in lounge. Check out our Facebook for a listing of current program offerings for Fall & Spring semesters as well as school and summer break programs.

Current programs include:

Drop-in Lounge for middle and high school aged youth
Craft class provided for elementary school aged youth
Cooking classes for elementary, middle and high school aged youth
Summer Fun Weeks: day camp for elementary school aged youth
Winter Fun & Spring Fun Weeks: recreational and educational activities provided to elementary school aged youth during winter and spring break recess.

Se brindan programas recreativos a los niños en edad escolar dentro del distrito escolar Patchogue Medford para proporcionar actividades saludables después de la escuela para mantenerlos activos y comprometidos socialmente en un entorno seguro y de apoyo. Las actividades incluyen manualidades, cocina, clases de guitarra, actuación, danza, yoga, club de trabajo a domicilio y un salón de descanso. Visite nuestro Facebook para obtener una lista de las ofertas de programas actuales para los semestres de otoño y primavera, así como también para los programas escolares y de vacaciones de verano.

Los programas actuales incluyen:

Se ofrece clase de artesanía: para jóvenes de primaria.
Clases de cocinar: para jóvenes de primaria, secundaria y preparatoria.
Drop-In Lounge: Para jóvenes de secundaria y preparatoria.
Semanas divertidas de verano: campamento de día para jóvenes de primaria
Diversión de invierno y semanas de diversión de primavera: actividades recreativas y educativas proporcionadas a jóvenes en edad escolar de primaria durante el recreo de invierno y primavera.

*If you cannot register online via form below, you could print out a physical copy of the registration form to bring into the agency.

Registration Form

Please make payment via Venmo:

@patmedyouth

Patchogue-Medford Youth & Community Services

HEALTH · SOCIAL SERVICES · RECREATION CENTER

SALUD · SERVICIOS SOCIALES · CENTRO DE RECREACION

SERVING FAMILIES AS A WHOLE

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