After-School Programs Registration Form - The Lower Hudson Valley Challenger Center

We must receive full payment before the program date. Please print this registration form, and mail the completed form with a check for the full amount of the program(s) made payable to:

The Lower Hudson Valley Challenger Center
225 Route 59, Airmont, NY 10901

If you have any questions, you can contact us at 845-357-3416 or e-mail us at director@lhvcc.com

Please LIST the name of the after-school program(s) of your choice and include the program(s) code and cost.

Program Name	Program Code	Program Cost

Child's name:

Age:

Gender:

Parent/Guardian:

Home phone with area code:

Street:

E-mail Address:

City:

State:

Zip:

Parent/Guardian Cell phone:

Work Phone:

Emergency name and contact number:

Allergies/Medications

Parent Signature:

How did you hear about us? ____Newspaper ___Magazine ___Friend ___Brochure ____Flyer

____Internet ___Other (Explain_________________________________________)

Office Use Only

Payment:_____________

Check#:_____________