BETHPAGE DISCOVERY PROGRAM APPLICATION

I would like to register my son/daughter for the Bethpage Discovery Program

Childs Name: __________________________________________________

Grade entering September 2012: __________________________________________

Birth date: _____________________________________________

Parent's Name: ___________________________________________________________

Home Address: ____________________________________________________________

Home Telephone #:______________________________ Cell phone #: ____________________________

Emergency Contact Name & Phone # from 7/10- 8/16:__________________________________________

My child may be picked up by: ______________________________________________________________

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