2026 YOUTH BUREAU'S REGISTRATION FORM

2026 REGISTRATION FORM

City of Peekskill Youth Bureau

828 Main Street, Peekskill, New York 10566

Ph: (914) 734-8419 * Fax: (914) 864-0150

THIS REGISTRATION FORM IS FOR PARENTS TO FILL OUT.

**APPLICATION IS NOT COMPLETE IF EVERY SECTION IS NOT FILLED OUT/AND OR SIGNED.
City of Peekskill Youth Bureau Statement of Policy

Requirement

The City of Peekskill Youth Bureau is open to all school-age children in grades 5 through 12 who live in Peekskill and the surrounding areas. All children are welcome regardless of sex, race, color, or national origin. Before your child may participate in any program, all required forms must be fully completed and signed.

Youth Bureau Operating Hours

September – June: Monday through Friday, 9:00 AM – 6:00 PM
Summer Hours: Monday through Friday, 8:30 AM – 4:00 PM

Both the Youth Bureau administrative office and all programs follow the City of Peekskill’s operating schedule. Any changes to hours for holidays or school vacation programming will be announced at least two weeks in advance.

Withdrawal

A child may be asked to withdraw from a Youth Bureau program if, in the judgment of the professional staff, the child is unable to function positively within the group setting or if the program is unable to meet the child’s specific needs. Parents or guardians agree to inform the Youth Bureau at the time of registration of any special needs that may require modifications to the child’s program activities.

Staff

The staff-to-child ratio will be approximately 1:10 for primary grades and 1:15 for middle/high school participants. Children will be supervised at all times.

Health

If it appears that a child’s health may pose a risk to other children, parents or guardians will be contacted and required to pick up their child immediately. Youth Bureau staff will not administer medication of any kind, nor may a child self-administer medication while in our care. In the event of a medical emergency, we rely on local emergency services to provide urgent care.

Food Service Arrangements

On some days, nutritious snacks are provided by the City of Peekskill Youth Bureau.

Transportation

The Youth Bureau does not provide transportation to and from the program.

Dismissal Arrangements

If any person listed on your child’s registration form is legally barred from having contact with or picking up your child, you must notify the Youth Bureau staff in writing and provide the appropriate legal documentation. Without such documentation, the Youth Bureau cannot prevent a parent or guardian from seeing or picking up a child.
YOUTH BUREAU'S 2026 REGISTRATION

Register for the following programs below:
- Rising Stars Program: September - June (Ages: 10-13)
- Rising Tide Boatbuilding: January - October (Boys ages 13-18)
- LIFT Summer Bridge Program: July - August 6 weeks (Ages 10-13)
- Peekskill Youth Council: September - June (Ages: 14 -18)
- SRAEP: Boys & Girls (Ages 14 - 18)
- Summer Employment (SYEP): Boys & Girls (Ages 14-20)
- Summer Employment (SYETP): Boys & Girls (Ages 18-24)
- Youth Volunteers; High School Only
*ALL PROGRAMS AT THE YOUTH BUREAU ARE FREE!
Rising Stars (ages 10-13)Rising Tide Boatbuilding (ages 13- 18)LIFT Summer Bridge Program (ages 10-13)Peekskill Youth Council (ages 14-18)Summer Employment SRAEP (ages 14-18)Summer Employment SYEP ( ages 14-20)Summer Employment SYETP (ages 16-24)Youth Volunteers (High School Only)
REGISTRATION - STUDENT INFORMATION
Student's first and last Name*
Date of Birth*

MonthDayYear
Gender*
Full Home Address*
Apt#
Zip*
Home Phone*
Ethnicity/Race*
Age*
Grade (January 2026)*
HillcrestPMSPHSCollege/Out of SchoolOut of District
Name of School if student is outside the District:
PARENT/GUARDIAN INFORMATION
Mother's Name*
Mother's Work Number*
Mother's Cell Phone*
Mother's EMAIL*
Father's Name
Father's Work Number
Father's Cell Phone
For notification purposes, please provide an Email address to be used to contact you:
example@example.com
EMERGENCY CONTACT INFORMATION (Person OTHER than parent/guardian required for emergency contact)
1st Emergency Contact's Name*
Phone*
Relationship to child*
2nd Emergency Contact's Name*
Phone*
Relationship to child*
MEDICAL HISTORY RELEASE
Child's Name*
YesNo
YesNo
If yes, please name the prescribed medications.*
AspirinPenicillinCodeinePeanutsMetalAcrylicLocal AnestheticsOther
If yes, please explain:
AsthmaEpilepsy or SeizuresHearing LossBreathing ProblemsFainting Spells/DizzinessKidney ProblemsBruise EasilyRecurring Ear InfectionsPsychiatric CareCancerFrequent HeadachesShinglesHives or RashHeart MurmurSinus TroubleCongenital Heart FailureHepatitis AStomach/Intestinal DiseaseDiabetesHepatitis B or CTuberculosis
YesNo
If Yes, please explain*
In the event of injury, I grant permission to take my child to a hospital for treatment, to include ambulance transportation, evaluation of injuries, x-rays and needed care.
YesNo
To the best of my knowledge, the questions on this Medical Form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the City of Peekskill Youth Bureau of any changes to my child's medical status.
Signature of Parent/Guardian *

Clear
Date

MonthDayYear
ARRANGEMENTS FOR DISMISSAL RELEASE
My child is to be dismissed in the following manner (Check all that apply):

Any changes to these arrangements must be made in writing to the Youth Bureau Director
YesNo
My child may be released to the following person(s).
1st Name*
Contact Number:*
2nd Name
Contact Number:
DISMISSAL ARRANGEMENTS: If any person listed on this form is legally barred from having contact with or picking up your child, you must notify the Youth Bureau Director of this in writing and provide legal documentation to that effect. Without such documentation, we cannot prevent a parent from seeing or picking up a child.
I have read, understand and agree with the terms of this release. Please Initial*

Clear
RELEASE OF LIABLILTY
In consideration of your acceptance of my child for his/her participation in the activities/programs of the City of Peekskill Youth Bureau, I agree that I am aware of the inherent dangers and risks involved in these activities/programs, including bodily injury which may be the result of strenuous activity or other causes related to these activities/programs. I agree to release and hold harmless the City of Peekskill, its officials, officers, agents, employees, and volunteers, from and against any liability, damage, or claim of any nature arising out of, or in any way related to, my child's participation in these activities/programs except those things caused by the sole negligence of the City. I understand that the City of Peekskill does not provide accident or medical insurance, and I am financially responsible for any medical expense whatsoever. I am advised to consult my child's physician before allowing my child to participate in any strenuous activity.
I have read, understand and agree with the terms of this release. Please initial*

Clear
PHOTO/VIDEO CONSENT RELEASE
The City of Peekskill Youth Bureau may videotape/photograph my child and use such videotape/ photographs for publication/broadcast/website. I waive any claim I might have against the City of Peekskill Youth Bureau arising from the use of such videotape/photographs. I understand that such information could subsequently be used by other media.
I have read, understand and agree with the terms of this release. Please initial*

Clear
Type a question
EDUCATIONAL INFORMATION RELEASE

I give permission for the release of the following information from my child's school to the staff of the City of Peekskill Youth Bureau: exchanges of information with teachers, social workers, guidance counselors, psychologists and school officials, as these relate to the student's behavior and academic needs. This information is strictly confidential and will be treated as such by the City of Peekskill Youth Bureau in working with my child.
I have read, understand and agree with the terms of this release. Please initial*

Clear
YesNo
YesNo
If yes, please describe these modifications
FIELD TRIPS/OUTINGS PERMISSION RELEASE

On occasion, and with advance notice, the City of Peekskill Youth Bureau may take trips within the City of Peekskill by foot, van, or bus. Please initial below to indicate your permission for your child to participate in these trips and to ride in the vehicle provided for the trip.
I have read, understand and agree with the terms of this release. Please initial*

Clear
POLICIES ACKNOWLEDGEMENT

I have read and agree to all of the policies set forth within this registration form.

PARENT'S SIGNATURE
Clear
Date

MonthDayYear
Should be Empty:

REGISTRATION - STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

MEDICAL HISTORY RELEASE

ARRANGEMENTS FOR DISMISSAL RELEASE

My child may be released to the following person(s).

RELEASE OF LIABLILTY

PHOTO/VIDEO CONSENT RELEASE