Rye Brook Parks and Recreation 2016-2017 Winter Activities
ONLINE REGISTRATION begins MONDAY, DECEMBER 19, 2016 @ 9:30 PM
Dear Rye Brook Resident, Rye Brook Recreation is committed to providing quality recreation programs. In the winter months, our recreation programs are moved inside the schools, Bellefair gym and the Anthony J. Posillipo Community Center to get our participants out of the frigid temperatures. The Recreation Department offers basketball (youth and adult), bowling, zumba and many other activities. If you are cooped up, come out and cheer on the participants. On-line registration for winter activities will begin on Monday, December 19th at 9:30pm. For all outside contractor program registration, you may register on-line and mail your payment to the Recreation office. If your payment is not received within 7 days, your registration will be cancelled and we will accept the next wait-listed family. If you do not have access to a computer, our recreation staff will guide you through the process. Your data entry will allow us to get the recreation information to your household in an efficient and timely manner. To register for programs, simply go to the Villageâ€™s website at www.ryebrook.org, scroll down the home page and you will see a section that will prompt you to register for programs. This link will bring you to Community Pass to register. This January, Rye Brook Little League will be hosting four baseball clinics at the Blind Brook High School on Wednesday evenings beginning on January 4th from 7-9pm in the high school and middle school gyms. There will be no cost for current little leaguers. Three instructors will work with our esteemed Little League Coaches to provide a high quality clinic in which we hope will be beneficial to all that participate. There will be two sessions focusing on pitching and two sessions focusing on hitting. We hope that Rye Brook Recreation is meeting your recreational needs. I join my staff in wishing you and your families a healthy and rewarding 2017New Year and look forward to seeing you at some of our many recreational activities. Happy Holidays, Robert Bertolacci Parks and Recreation Superintendent
DEPARTMENT OF PARKS AND RECREATION RECREATION STAFF
Robert Bertolacci, Superintendent Janice Kunicki, Sr. Recreation Leader Rocco Furano, Recreation Assistant Jennifer Leichter, Office Assistant
Paul Vinci, Parks Foreman Ted Warzoha, Parks Attendant Joe Orlando, Parks Attendant Justin DiSanto, Parks Attendant
The Parks and Recreation office is located At Village Hall, 938 King Street. The office hours are 8:30am - 4:30pm Monday through Friday.
MAILING ADDRESS Rye Brook Recreation 938 King Street Rye Brook , NY 10573
Parks & Recreation Telephone Numbers Office…………….939-3235 Parks Department..939-1796 Senior Adults…….939-7904
Susan Epstein-David Heiser Jason Klein-Jeff Rednick Village Board meets the 2nd and 4th Tuesday of each month.
PARKS AND RECREATION ADVISORY COUNCIL
Dr. Richard Buzin – Chairman Susan Gardner – Mike Keilman Emma Saghir– Scott Tillison Adam Zahl
Page General Information ·············· 4-5 Youth Basketball ·················· 6 Youth Activities ···················· 7-8 Other Activities…………………8 Spring Preview ····················· 9 Rye Brook Little League ········· 9-10 Special Events ······················ 11 Day Camps ························· 12 Special Population Programs ·· 12 Camp Health Form ·············· 13 Adult Activities ··················· 14 Rye Brook Seniors ··············· 15-17 Registration Form ················ 18
GENERAL INFORMATION REFUNDS: All refunds requested prior to the start of the program will be given with a $40.00 handling fee deducted.
SPECIAL NOTE Rye Brook Parks and Recreation Department is always looking for new and innovative talent within its community boundaries. If you possess a skill and the ability to teach it, please mail us your resume.
All refunds after the start of the program will be given with the greater of a prorated rate or $40.00 handling fee deducted. There will be NO Little League Sponsors Sought for Our 2017 refunds given for youth sport leagues after the Spring Season teams are made. Please note that all programs will not run when school is closed or cancelled. Residents wishing additional information should contact the Recreation Office at 939-3235. CANCELLATIONS: Rye Brook Recreation will use itsâ€™ Community Pass email system to notify participants of cancellations, as well as the Villages website for updates. VILLAGE PARKS: Garibaldi, Harkness, Pine Ridge, Rye Brook Athletic Fields, and Rye Hills Parks are available to resident groups on a permit basis. If your organization wishes to reserve a park for a specific date, permits are available at the Recreation office or on our website at www.ryebrook.org/recreation.
The sponsorship fee for our spring Little League Baseball is $600 for new sponsors and $400 for returning sponsors. Each sponsor will have their company name on a banner that will be placed on the fence at Pine Ridge Park for the entire spring, summer and fall seasons and have their company listed on our website as a sponsor. The sponsors name will also be printed on the back of the jerseys and all team schedules. Sponsors will also receive a plaque with their team picture attached. For additional information, please call the Rye Brook Recreation Department at 939-7054.
Advertising Sponsors Sought for 2017 Spring/ Summer Brochure The Rye Brook Parks and Recreation Department will place business card size ads in our Activity Brochure. We are seeking a limited The Rye Brook Parks and Recreation Departnumber of area businesses to advertise as sponment welcomes residents of all abilities. Any sors in the upcoming Activity Brochure. resident with a disability needing special assis- AD RATE (3) TIMES: $125.00 tance should contact the Superintendent at 939- AD RATE (2) TIMES: $100.00 7054. AD RATE (1) TIMES: $ 75.00 Anthony J. Posillipo Community Center The Center is utilized for Senior Citizens on weekdays, recreation on week nights and is available for rental on the weekends. The center will be closed on December 26, 2016 and January 2, 2017. For more information contact the Center directly at 939-7904.
Should you have an interest, please enclose your business card and make your check payable to Rye Brook Recreation and mail to Rye Brook Recreation, 938 King Street, Rye Brook, New York 10573. Telephone #: 937-6663 Fax #: 937-7438 Office Hours: 8:30am â€“ 4:30pm (M - F)
YOUTH BASKETBALL KINDERGARTEN BASKETBALL
YOUTH BASKETBALL CLINIC
This mid-winter recess basketball clinic is designed for boys and girls 4th thru 7th grade who want to improve their offensive and defensive skills for the upcoming AAU season, CYO tournament and invitational team tournaments. The clinic is designed to develop the skills in shooting, dribbling, and passing. The last half hour is designed to have the players play games and practice their newly acquired skills. Who: Boys & Girls (4th thru 7th Grade) Location: Blind Brook High School Gym Day/Time: Tuesday-Friday 4-7 Boys, 9:00 - 10:30am 1ST GRADE BASKETBALL 4-7 Girls, 10:30am - 12:00pm This program is set up to help children work on Dates: February 21 - 24 their dribbling and passing skills and introduc- Instructor: Manny Martinez es them to shooting by utilizing our 8â€™ baskets. BBHS Varsity Basketball Coach Games will be played at the end of each session. Fee: $150.00 Who: 1st Grade Boys & Girls Checks payable to Rye Brook Recreation. Location: Ridge Street School Old Gym BOYS BASKETBALL (8th thru 11th Grade) Day/Time: Thursdays 3:30pm - 4:30pm Location: Blind Brook High School Gym Dates: January 5 - February 9 Day/Time: Saturdays, 1:00 - 4:00pm Max #: 20 (first come, first serve) Dates: On-Going Fee: $75.00 Fee: $205.00 Checks payable to Rye Brook Recreation Checks payable to Rye Brook Recreation. Contact Janice Kunicki at the Recreation Office RYE BROOK YOUTH BASKETBALL (305-2947) for further information. (IN PROGRESS) Boys and Girls (2nd thru 7th Grade) Location: RSS New and Old Gyms Belle Fair Gym Day/Time: Schedules available on ryebrook.org Fee: $205.00 Checks payable to Rye Brook Recreation This program is set up to help children work on their dribbling and passing skills and introduces them to shooting by utilizing our lower baskets. Games will be played at the end of each session. Who : Kindergarten Boys & Girls Location: Ridge Street School Old Gym Day/Time: Wednesday 3:30pm - 4:30pm Dates: January 4 - February 8 Max #: 20 (first come, first serve) Fee: $75.00 Checks payable to Rye Brook Recreation
HAPPY HOLIDAYS 5
YOUTH ACTIVITIES YOUTH BOWLING LEAGUE
FUN WITH PIANO (IN PROGRESS)
Who: Boys & Girls (2nd – 9th Grade) Location: Spins Bowl of Mount Kisco Day/Time: Monday, 3:10-6:00pm Dates: January 9th - March 13th No-Session: 1/16 or 2/20 Make-Up: 3/20 Fee: $200.00 Supervisor: Janice Kunicki Meet at Ridge Street School at 3:10pm Transportation will be provided. Checks payable to Rye Brook Recreation
Piano study offers unique benefits. In addition to the experience of making music, students increase concentration skills, enhance coordination between brain hemispheres and gain self-confidence through performance of increasingly challenging material. The Fun with Piano program, run by Julliard trained instructor, Dinah Basson, emphasizes the fun in learning through the choice of enjoyable repertoire: Ages: 6 – 13 and Adults Location: Anthony J. Posillipo Center Day/time: Mondays & Wednesdays Instructor: Dinah Basson New session begins in January 2017 Checks payable to Dinah Basson Materials not included. For more information call Dinah Basson (212) 787-2972.
HOBBY QUEST “FLYING MACHINES”
Time to turn up your imagination and look into the future with Hobby Quest’s “Flight – The Next Generation! This semester we’re building all new planes from the future! Also, for the first time ever, we’ll be flying a super cool remote control helicopter! Build it! Fly it! Keep it! Who: K-5th Grade Boys & Girls Min/Max: 8/16 Location: RSS Rm TBD Day/Time: Wednesdays; 3:10pm-4:20pm Dates: January 11th – March 8th No Class: January 16th, February 22nd Snow Date: March 20th Fee: $150.00 Supervisor- Hobby Quest Flight Captain.
Hobby Quest’s “Denim Dreams”
Take your love of denim to the next level with Hobby Quest’s Denim Dreams! This session we are crazy about denim, and are creating really cool clothes and accessories out of the most versatile fabric out there! Who: Min/Max: Location: Day/Time: Dates: No Class: Snow Date: Fee:
K-5th Grade Boys & Girls 8/16 RSS Rm TBD Thursdays; 3:10pm-4:20pm
January 12th – March 9th February 23rd March 15th $150.00
Supervisor- Hobby Quest Fashion Team
ICE SKATING INSTRUCTION II Teachers will escort children to the designated area to meet with the Recreation Staff. Who: 1st - 8th Grade Location: Hommocks Ice Rink Day/Time: Tuesdays, 3:10pm - 6:00pm Dates: January 10th- March 7th (no session 2/21) Fee: $200.00 Supervisor: Rocco Furano Check payable to Rye Brook Recreation
LITTLE LEAGUE WINTER BASEBALL CLINICS
There will be Little League Winter Clinics on Wednesday evenings for all Rookie and Little League players to work on skills for the upcoming baseball season. Two clinics will be held to emphasize hitting and two for pitching. Who: Rookie, Minor and Major League players Date: January 4, 11, 18, 25 Times: Under 10 players, 7-8pm 10-12 year olds, 8-9pm Where: Blind Brook High School gym Instructor: 21st Century Sports
SPRING PREVIEW 2017 RYE BROOK PEE WEE SOCCER AND PRE-TRAVEL ALL STAR SOCCER
Elite Soccer Academy, L.L.C. is offering a 7-week Pee Wee and Pre Travel Soccer program for children between the ages of 4 - 8 years old. The curriculum is designed on developing the fundamental skills of dribbling, passing, trapping and shooting. Each session will conclude with small-sided games. Emphasis will be placed on teamwork and good sportsmanship and having fun.
ROOKIE LEAGUE This parent-coached league will focus on the fundamentals of teamwork and the basic skills of baseball/softball for 1st and 2nd graders. Teams will be made by the Recreation Department. Requests will not be honored. Teams will play two games per week. Games will take place on Thursday or Friday nights and Saturday mornings.
KINDERGARTEN T-BALL This fundamental program will teach the basics of baseball with an emphasis on teamwork and improving oneâ€™s ability in throwing, catching, hitting and running through a variety of fun drills and games in an instructional format. This program is for current Kindergarteners only.
TEEN CENTER The Teen Center gives 6th, 7th, 8th and 9th graders an opportunity to go on trips periodically and to attend various events throughout the school year. This helps build new friendships, responsibility and maturity. A completed contract and application is required for membership. Events will be planned throughout the school year. Notification will be by email of these new events.
Who: 6th, 7th, 8th and 9th Graders DateS: TBA
RYE BROOK LITTLE LEAGUE This Spring Rye Brook Little League will begin itsâ€™ 14th season as an accredited Little League program. We plan on getting your 2017 Little League season underway earlier so that we can have more structured practices prior to the start of the season. The Little League baseball and Little League softball ratings will take place in early March. Practices will begin indoors during the month of March until the weather breaks. Coaches will attend a mandatory coaches clinic to enhance their ability to teach the skills to our Little Leaguers. There will be practices built into the first half of the season on a weekly basis. Rye Brook Little League will have a dedicated website. The website will be the location to go to find out your league standings, scores, rosters, cancellations and statistics. The opening day parade will take place on Saturday April 22, 2017. Rye Brook Little League will once again place teams in the District 20 tournament vying for a chance to play in the Little League World Series in Williamsport Pennsylvania. To qualify for a chance to make the team, individuals must be registered for Little League, participate in a minimum of 60% of the games and be available from June through August. The minor league baseball program will utilize a pitching machine for all league games. There will be clinics every Friday afternoon emphasizing pitching, hitting and fielding. We are also working with Port Chester Little League And Irvington Recreation on an interleague schedule. The 2017 Rye Brook Little League will have playoffs for all Major league teams culminating in a Rye Brook Champion. We hope to see everyone at the ratings and hope to provide you with a wonderful and memorable Little League season.
Online Registration Begins Monday December 19th 9:30pm 7
RYE BROOK LITTLE LEAGUE RYE BROOK LITTLE LEAGUE LITTLE LEAGUE WINTER CLINICS OPENING DAY PARADE/CEREMONIES There will be Little League Winter Clinics on Wednes-
The Little League opening day parade/ceremonies will take place on Saturday, April 22, 2017 All Little League and Rookie League players in uniform will report to the parking lot near Ridge Street School New Gym at 12:30pm to participate in the parade.
LITTLE LEAGUE BOYS AND GIRLS RATING SESSION: SATURDAY MARCH 11 9:00AM - 12:00PM BBHS GYM If you did not play in the Major Leagues last year or you are a newcomer you have to be rated. All others do not have to attend but must go online to register. All participants must be registered prior to ratings.
LITTLE LEAGUE SPONSORS BEING SOUGHT FOR OUR 2017 SPRING SEASON.
The sponsorship fee for our spring Little League Baseball is $600 for new sponsors and $400 for returning sponsors. Each sponsor will have their company name on a banner that will be placed on the fence at Pine Ridge Park for the entire spring, summer and fall seasons as well as being listed on the Little League website as a sponsor. The sponsors name will also be printed on the back of the jerseys and all team schedules. Sponsors will also receive a plaque with their team picture attached. For additional information, please call the Rye Brook Recreation Department at 937-6663.
day evenings for all Rookie and Little League players to work on skills for the upcoming baseball season. Two clinics will be held to emphasize hitting and two for pitching. Who: Rookie, Minor and Major League players Date: January 4, 11, 18, 25 Times: Under 10 players, 7-8pm 10-12 year olds, 8-9pm Where: Blind Brook High School gym Instructor: 21st Century Sports
MINOR LEAGUE BASEBALL This program is for boys 9 and 10 years of age prior to January 1st, 2017 or 8 year old 3rd graders. Resident teams play against each other. A pitching machine will be used for all league games. Official Little League baseballs are used. Fee: $140.00
MAJOR LEAGUE BASEBALL This program is for boys 11 and 12 years of age prior to January 1st, 2017 or 10 year old 5th graders. Resident teams play against each other. Players pitch for all six innings using official Little League baseballs. Fee: $140.00
MINOR LEAGUE GIRLS SOFTBALL This program is for girls 9 and 10 years of age prior to January 1, 2017 or 8 year-old 3rd graders. League teams play against each other. Coaches pitch to batters. Fee: $140.00
MAJOR LEAGUE GIRLS SOFTBALL This program is for girls 11 and 12 years of age prior to January 1, 2017 or 10 year old 5th graders. League teams play against each other. Players pitch for all six innings using official Little League softballs. Fee: $140.00
Happy Holidays 8
SPECIAL EVENTS LUNCH WITH THE BUNNY This event will feature lunch, entertainment, and a visit from a special friend. The deadline to sign up is March 31, 2017. Registration is free and limited for this event. Who: 3 - 9 year olds (Rye Brook Residents Preference) Location: Anthony J. Posillipo Community Ctr. Day/Time: Saturday, 11:30am Date: April 1, 2017 Max#: 60 kids (Limited 2 guardians per family) Fee: FREE
RYE BROOKâ€™S 35TH BIRTHDAY CELEBRATION Date: Saturday June 17, 2017 Volunteers are needed for the Birthday Celebration. Volunteers are needed for rides supervision, food distribution, and parking cars. As in the past we will again be holding a food drive. Please bring canned goods with you the day of the event. For additional information, please contact the Recreation Office at 937-6663.
RYE BROOK DAY CAMPS RECREATION DAY CAMP Rye Brook Day Camp will be offered to children entering Kindergarten (proof required) in September 2017 to 6th grade. The camp will be limited to 250 children. Residents are given preference until May 1, 2017 (first come first served). All campers will attend camp at Crawford Park. A limited number of scholarships are available for Rye Brook residents only. Those in need of camp scholarships should contact Rocco Furano by April 7, 2017 at 914-305-2948. Rye Brook Day Camp will run for 6 weeks from July 3rd through August 11th. Fee: RESIDENT NON-RES Prior to 5/1 (6 weeks) $960 ____ Add Child $760 ____ After 5/1 (6 weeks) $1110 $1240 Add Child $860 $1040 2 weeks $520 $750
RYE BROOK TEEN SUMMER CRAZE Rye Book Teen Summer Craze is a travel camp for 7th, 8th, 9th, & 10th graders (September 2017) . Campers will go on 5 trips a week. All trips are included in the registration. The camp is limited to 110 campers who will be accepted on first come, first serve basis.. If you have any questions/concerns please call Janice at 305-2947. Who: Boys & Girls (7th thru 9th Grade) Location: Harkness Park Day/Time: Mon - Fri (8:30am—3:30pm) Dates: July 3rd - August 11th Trips: TBA Fee: RESIDENT NON-RES. Prior to 5/1 (6wks.) $1690 _____ After 5/1 (6 wks.) $1790 $2140 2 weeks $910 $1160
SPECIAL POPULATION PROGRAMS ACTIVITIES RYE BROOK/PORT CHESTER ASSOCIThe Village of Rye Brook Recreation Department ATION FOR RETARDED CITIZENS SOUTHEAST CONSORTIUM
is part of the South East Consortium for Special Services Inc., which is a “not-for-profit” organization, dedicated to providing leisure services to eligible citizens with developmental or other disabilities. The South East Consortium offers a variety of programs and services in an effort to meet the physical, social, cultural and quality of life needs of children and adults of all ages and functioning abilities. We try to base all activities on the appropriateness of the participant and availability of resources. We welcome your participation. For further information, contact the South East Consortium, 740 West Boston Post Road, Suite 312, Mamaroneck, New York 10453 or call (914) 6985232.
Special recreation programs are offered for people who are trainable for employment. For further information contact Letitia Chuckas at 9397917. Location: King Street School
RYE BROOK RECREATION CAMP HEALTH AND REGISTRATION FORM Please fill out form and return to the Recreation Department with a check. Questions 1 through 6 are to be completed by your child’s physician and Questions 7-13 is to be completed by a legal guardian. LAST NAME ADDRESS SCHOOL
FIRST NAME CITY/STATE Grade entering in Sept. 2017
DATE OF BIRTH ZIP CODE
ALL CHILDREN ATTENDING DAY CAMP MUST HAVE AN UP TO DATE IMMUNIZATION RECORD THAT INCLUDES THE FOLLOWING (PLEASE HAVE YOUR DOCTOR LIST THE DATES).
Date of shot
1. Four or more doses of Diphtheria/Tetanus Toxoid ____/_____/ 2. Three or more doses of Oral Polio Vaccine or four or more doses of Inactive Polio Vaccine Salk given after 1968 ____/_____/ 3. One dose of live Measles Vaccine given after 1 year of age. ____/_____/ 4. One dose of live Mumps Vaccine given after 1 year of age. ____/_____/ 5. One dose of live Rubella Vaccine given after 1 year of age. ____/_____/ 6. Is the child taking any prescribed medication? YES NO If the answer is yes, what is the medication? Would your child be taking the medication during the camp day? YES NO _______________ Physician’s Signature Date 7. Has your child had any recent operation or injury? YES NO If yes, please explain 8. Has your child been exposed to any communicable disease within the last 3 weeks? YES NO If yes please list 9. Please list food, which your child is allergic to if any Please list drug, which your child is allergic to if any Is your child allergic to insect/bee bites? YES NO 10. is there any emotional or physical disturbance? YES NO If yes what treatment or care has been given? 11. Do you want your child to participate in our swim program? YES NO 12. Is there any reason why your child may not participate in any activities? YES NO___ If so, please explain FOR EMERGENCY USE: Parents’ daytime numbers ( ) ( ) If a parent cannot be reached: Name/Relationship Telephone numbers ( ) ( ) Neighbor or relative who would know where a parent could be reached, or who would be able to pickup the child if necessary: Name: Address Phone ( ) Child's Physician: Address Phone ( ) I hereby authorize my child/children whose name(s) appears above to participate in the above program/s sponsored by the Rye Brook Parks and Recreation Department. I hereby release the Village of Rye Brook, Carver Center, their servants and employees from any liability for personal injuries or property damage sustained by my child/children, in connection with such participation. In case of injury, I authorize a Recreation Staff member to take my child/children to the hospital for treatment. I hereby authorize my child to swim at the Carver Center.
PIECE CORP QUILTING
MEN’S ADULT BASKETBALL
If you know the basics A recreation staff person will confirm with of sewing and would the school each week for this program. In like to share ideas case the school will not be available, particiwith a group, come pants in the program will be notified by eand join other quilt- mail prior to the weekend. Adult Men ers on Wednesday Who: evenings. Novices wel- Location: BBHS & BBMS come. This group as Go always will be there to encourage and support other group members. DITCH THE Who: Adults WORKOUT– JOIN THE PARTY! Location: AJP Community Center nd th Tired of exercises, Let’s Day/Time: 2 and 4 Wed. of the Month Zumba! Zumba is de7:30pm - 9:30pm rived from a Colombian word meaning move Date: On going through May fast and have fun”. It is a Latin-inspired dance fitness class that incorporates high-energy inFee: FREE ternational music and easy-to-follow dance movements. People who’ve tried this musclepumping, caloric-burning workout say its so much fun, you’ll get a workout without feeling like you’ve worked out! Taught by: RitaMarcia Fernandes Freitas a licensed Zumba instructor,. When: Thursdays, 7:30pm - 8:30pm Dates: On Going Location: Anthony J. Posillipo Fee: 5 or more classes $10.00/class Walk Ins:
Yoga is a dynamic fusion of exercise. We will be focusing on strengthening ones core and developing flexibility. Who: Adults Location: AJP Community Center Day/Time: Monday, 7:00pm—8:15pm Dates: Monthly on-going Instructor: Monica Pardo Fee: 6 sessions for $100.00 Make checks payable to Monica Pardo
RYE BROOK PARKS & RECREATION WINTER 2016 – 2017 REGISTRATION FORM You may register by mail or in person. Checks or Credit Card information must accompany this registration from. Mail to Rye Brook Recreation Department, 938 King Street, Rye Brook, N. Y. 10573. (unless otherwise specified in the brochure). NAME:_____________________________________________________________SEX: M______F_____ ADDRESS:____________________________________________________________________________ CITY:__________________________________________STATE:_______________ZIP:_____________ HOME TELEPHONE #:(______)______-________BUSINESS TELEPHONE #(_____)_____-_________ SCHOOL:____________________________________________GRADE:_____D.O.B.:______________ IN CASE OF AN EMERGENCY CONTACT PERSON:_______________________________________ TELEPHONE #: (______)______-__________ E-MAIL:_______________________________________ ANY CONCERNS/REQUESTS:__________________________________________________________ PROGRAM:_____________________________________________________FEE:_________________ PROGRAM:_____________________________________________________FEE:_________________ PROGRAM:___________________________________________ _________FEE:_________________ TOTAL FEE ENCLOSED:_________________________ I hereby authorize myself whose name/s appears above to participate in the above program, sponsored by the Rye Brook Parks and Recreation Department. I hereby release the Village of Rye Brook, their servants, employees and volunteers from any liability for personal injuries or property damage sustained by my child/ children in connection with such participation. In case of injury, I authorize the Recreation staff members to take my child to the hospital for treatment. __________________________________ PARENT/GUARDIAN SIGNATURE BILLING INFORMATION: WE ACCEPT THE FOLLOWING CARDS: DISCOVER – MASTERCARD – VISA NAME:______________________________________________________________________________ ADDRESS:___________________________________________________________________________ ADDRESS 2:__________________________________________________________________________
CITY:_________________________ STATE:_______________ ZIP CODE:___________ PHONE #:___________________________________(USE FORMAT XXX-XXX-XXXX) CREDIT CARD INFORMATION: TYPE OF CARD:______________________________________________________________________ CARD NUMBER:______________________________________________________________________ SECURITY CODE:__________________________EXPIRATION DATE:________________________