2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number*
8. Participant is the same as above

   1. Yes
10. Participant First Name
11. Participant Last Name
13. Youth Phone*
14. Youth Email*
16. Mailing Address
    Street, City, State, Zip
18. Grade:

    Check flyer for grade level requirements!

19. Ethnicity

    1. Hispanic or Latino
    2. White or Caucasian
    3. Black or African American
    4. American Indian or Alaskan Native
20. Gender:
    -- Select One --MaleFemale
22. Reply Email
23. Date of Birth**
    Date of Birth*
25. School
27. How did you hear about this program? Please place a to which category (or categories) apply to you:*

    1. Postcard/Direct Mailing
    2. Social Media
    3. School
    4. Town’s Website
    5. Email
29. Emergency Contact Name*
31. The following have permission to pick up my child:*
32. Food Allergies or Other Health Concerns:*
34. I give permission for my child (ren)*

    1. I agree - SPRING BREAK 2026

    I give permission for my child to attend the Town of Southampton Youth Bureau’s Spring Break Schedule at the Flanders Youth Center, 655 Flanders Road from Tuesday, April 7, 2026 - Friday, April 10, 2026. I also give permission for my child to be transported on Tuesday, April 7, 2026 from the Flanders Youth Center, 655 Flanders Road to Escape Games LI, 718 Portion Road, Ronkonkoma (round trip), on Thursday, April 8, 2026 from the Flanders Youth Center, 655 Flanders Road to Vanderbilt Planetarium, 180 Little Neck Road, Centerport (round trip) , and on Friday, April 10, 2026 from Flanders Youth Center to SYS, 1370a Majors Path, Southampton (round trip) . I hereby shall release liability, waive any claims against, indemnify, defend and hold harmless the Town of Southampton, its officers, employees, contractors, agents and representatives from and against any and all demands, liabilities, losses, damages, expenses (including reasonable attorney’s fees) and judgments relating to or arising from my child’s participation in the Town of Southampton Youth Bureau’s Spring Break programs. I certify that my child’s health and physical condition are appropriate for participation in these activities. In the event of a medical emergency and I cannot be reached, I authorize the Town of Southampton Youth Bureau staff to seek emergency medical treatment. I also consent to photographs and video being taken of my child, understanding they may be used for promotional purposes.

36. Service (Convenience) Fee:
    A convenience fee of 2.5%, with a minimum fee of $1.95, will be charged by CSG Forte for transactions made with a Visa, MasterCard, Discover, or American Express card. Your personal information will not be shared with marketers or unaffiliated third parties.
38. Registration Fee*
    -- Select One --Escape Games LI - $35.00Video Games - $10.00Planetarium - $10.00
39. Cost of Activity
Leave This Blank:


45. Calculate Totals Proceed to Checkout

* indicates a required field