Town of Southampton Activities

New Registration

  1. Participant is the same as above
  2. Grade:*
  3. How did you hear about this program? Please place a to which category (or categories) apply to you:
  4. (Name / Relationship)
  5. I give permission for my child (ren)*

    I give permission for my child to attend the Town of Southampton Youth Bureau’s Discovery Club’s Life on Other Planets program at the Flanders Youth Center, 655 Flanders Road on Wednesdays from November 3rd - December 1st. 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 Discovery Club’s Life on Other Planets program. I certify that my child’s health and physical condition are appropriate for participation in these physical activities. I also understand that because of the current COVID-19 pandemic, certain health and safety procedures outlined by NYS and the CDC will be implemented upon arrival & dismissal of my child. I understand that they are important to ensure a safe environment for my child, other youth participants, and all program staff involved. 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 being taken of my child, understanding they may be used for promotional purposes.

  6. 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.
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