Survey - Members-Only Public Program Registration - Families

To register, please fill out the form below:

1.

Registrant Information (Parent/Guardian if registrant is under 18):

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

Yes, I would like to receive (or continue to receive) e-mail from the Conservancy including information about this event.

Remember me. What's this?

*2.

Question - Required - Please enter your Member ID number located on your Conservancy membership card:

*3.

Question - Required - Select the Conservancy program you are registering for:

*4.

Question - Required - Enter the date of the session you are registering for:

Month

Day

Year

5.

Question - Not Required - Please write in the names of all family members who plan to participate in this event.

(Maximum response 255 chars, approx. 5 rows of text)

Photo Consent

I hereby authorize and give consent to the Central Park Conservancy to copyright or publish all photographs or video in which I, the undersigned, appear while enrolled as a participant in their program. I further agree that the Central Park Conservancy may transfer, use or cause to be used, these photographs or videos for any and all exhibitions, public displays, commercials, art and advertising purposes without limitations or reservation.

*6.

Question - Required - Electronic Signature of Participant (or Parent/Guardian if participant is under 18).

7.

Question - Not Required - E-mail of Parent/Guardian (if participant is under 18):

*8.

Question - Required - Date of signature:

Month

Day

Year

Direct all questions regarding this form to:

Associate Director of Membership
14 East 60th Street, New York, NY 10022
Phone: 212.310.6639