We must receive full payment on or before the program date.
If you wish to pay by check, please print this registration form, and mail the completed form with a check for the specified amount (listed on the program page) made payable to the TOWN OF RAMAPO.
If you wish to pay by credit card, please call 845-357-3416 with your credit card information, and print and mail this registration form.

Please mail completed form to:
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  afterschool@LHVCC.com

Please LIST the program's name and include the program's start time and cost.
Program Name Program
Start Date 		Program
Start Time 		Program Cost
















Child's name:Age:
Date of Birth: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:
Please tell us about any issues we should be aware of regarding your child such as Allergies/Medications/Behavioral:
I understand that the TOWN OF RAMAPO does not offer accident insurance and that my personal insurance bears primary responsibility in case of accident. I authorize the use of photos for promotional purposes. A $15 fee is imposed for any checks returned from a bank for any reason.
Parent Signature:
How did you hear about us?  ___Newspaper  __Magazine  __Friend  ___Brochure  ____Flyer  ___Internet  ___Other (Explain_______________)
Office Use Only
Payment:_____________ Check#:_____________ 
The mission...to learn, to explore, to inspire...continues.