Big Apple Sports
459 Columbus Ave. Suite #188 New York, NY 10024 (212) 987-9865/53 Fax 987-9674
After School Application (FALL 2010-2011)
Name: ___________________________________________________ Age: ____________ Grade: _________
School: ___________________________________________ Room: __________________________________
Address: ______________________________________________ Apt.: ___________ Zip: ________________
Phone: ___________________________________ Pager/Cell: _______________________________________
Father: ________________________________________ Bus. Phone: _________________________________
Mother: _______________________________________ Bus. Phone: _________________________________
Emergency Contact: ______________________________________ Relation: __________________________
EC Phone: ____________________________________ ( Must be available between 2:35 and 6 PM)
Email_______________________________________________________________
The following adults are authorized to pick my child(ren) up from the program:
Name: ___________________________________ Relation: ________________ Phone: ________________
Name: ___________________________________ Relation: ________________ Phone: ________________
It is the responsibility of the Parent/Guardian to inform BASCI, in writing, if someone is not
legally permitted to pick your child(ren) up from the program. Prior notification must be
given to BASCI if someone other than the above listed will be picking the child(ren) up after
the program. Notification consists of a phone call to BASCI, giving a description of the
authorized person and a note from the Parent/Guardian.
My child(ren) may go home alone after the end of the program. ___________
I, the undersigned, being the Parent/Guardian certify that the applicant on this form is in good health and
that he/she has my permission to participate in this program. I fully understand that each participant
will engage in activities that involve the risk of serious injury which might result from their own actions,
the negligence of other participants, the rules of play, the condition of the premises, or any equipment
used. It is further understood that I shall not be entitled to any refunds or deductions for any absences or
illnesses during the term. Furthermore, I certify that I release the Big Apple Sports , its directors and
staff from liability for medical, dental, or instructions while at the Big Apple Sports Club,. . I also grant
consent and permission for any emergency treatment deemed necessary for my child. I further permit
such emergency treatment at the nearest available clinic, whether city or private. It is understood that no
refunds will be given after OCTOBER 1, 2010.
_________________________________________________ ____________________
Signature Date