2021 ESSK Enrollment Form: Early Rates CAMPER INFORMATION Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Phone #Gender*MaleFemaleGrade as of September 2020*1st2nd3rd4thSchool Attending in 2020-2021*Number of years at Park Shore Day Camp (include 2021)*123456789101112Would you like to utilize one of our payment plans?*YesNoPayment Plan Options*Click here to view the Payment Plan Options before making your selection.Payment Plan OnePayment Plan TwoPayment Plan ThreePayment Plan FourOther (Bookkeeping will contact you)PARENT INFORMATIONParent's Name* First Last Bus. PhoneCell #*Email* Parent 2 Name (Optional) First Last Bus. PhoneCell #Email EMERGENCY CONTACTSName*Relationship*Phone #*NameRelationshipPhone #Please select one camp session below for your childPlease select one session for your child:*Full Day (9:15 AM - 4:00 PM)Morning Only (9:15 AM - 12:15 PM)Child must have completed 1st - 4th Grade as of June 2021.Please select the Full-Day session:*8 Weeks: $7895 (Early) $8280 (Regular)6 Weeks: $6760 (Early) $7095 (Regular)4 Weeks: $4885 (Early) $5175 (Regular)2 Weeks: $2695 (Early) $2840 (Regular)Please select the Morning-Only session:*8 Weeks: $3945 (Early) $4140 (Regular)6 Weeks: $3380 (Early) $3550 (Regular)4 Weeks: $2440 (Early) $2590 (Regular)2 Weeks: $1355 (Early) $1420 (Regular)Add Lunch ($295):*YesNoAdd Lunch ($230):*YesNoAdd Lunch ($150):*YesNoAdd Lunch ($75):*YesNoSelect the session(s) for your child Session 1: 6/28 - 7/9 Session 2: 7/12 - 7/23 Session 3: 7/26 - 8/6 Session 4: 8/9 - 8/20 If you selected "2 Weeks" above, select any one session. If you selected "4 Weeks," select any two sessions. If you selected "6 Weeks," select any three sessions.Will you be utilizing Park Shore transportation?*YesNoPlease Choose All That Apply:* AM Pick Up 4:00PM Take Home Will you be utilizing Park Shore transportation?*YesNoPlease Choose If You Plan to Utilize the Morning Bus:* AM Pick Up Please use this box for additional Information you'd like to provide:How did you hear about us? Please check all that apply.* Google Facebook Instagram Yelp Advertisement Long Island Parent Living Huntington Village Connection Magazine LongIsland.com Mommy Poppins Macaroni Kid Attended Park Shore Day School Attended Rookie Day Attended free class at Extreme STEAM Science Kids Friend/Relative Park Shore Employee Place of work Drove by Other Recommended byCompanyOtherTo complete your registration, you MUST check the box below indicating that you have read and agree to the terms & conditions. Contracts will not be processed without a signature & deposit. Park Shore Country Day Camp will be closed on Monday, July 5, 2021. We will re-open on Tuesday, July 6, 2021. An enrollment deposit of $500 is required for each child, which is refundable for any reason up to Friday, March 5, 2021. There will be a 3% administrative fee added to your tuition. You can pay with check, cash or credit card. If you pay by check or cash we will waive the 3% fee. If you decide to use a credit card, we must have a credit card authorization form on file. The balance of all tuitions is due no later than Friday, April 16, 2021. It is understood that no part of the tuition fee or deposit, except that part covered under our normal sickness refund plan (Non-COVID and Non-communicable diseases), will be refunded after Friday, March 5, 2021. If a camper is absent due to illness or accident, as certified by a physician’s letter, for 5 consecutive camp days during the camp session, a pro-rata refund will be made for every day thereafter following our current refund policy. In the event camp is unable to open or is forced to begin late or close early due to circumstances beyond Park Shore’s control, we will reassess our refund policy. It is understood that camp days may not be substituted due to illness or any other absence. I hereby give my consent to have my child taken to and from various field trips by means of transportation used by Park Shore Country Day Camp if transportation protocols of social distancing change during the summer. In the event that I cannot be reached by phone in an emergency, I hereby give my permission to my family physician, any local physician or hospital and to Park Shore Country Day Camp to administer emergency treatment to my child. I hereby grant permission to use any photograph, film or other image for promotional purposes, including but not limited to brochures, DVDs, our website and Facebook page and other online postings. Binding Arbitration – I agree that any dispute concerning, relating, arising out of or referring to the subject matter of this contract shall be resolved exclusively by binding arbitration in Suffolk County, New York, according to the then existing commercial rules of the American Arbitration Association and the substantive laws of the state of New York. Park Shore Country Day Camp is licensed by the N.Y.S. Dept. of Health and is inspected twice yearly. Copies of the inspection are filed in the Health Dept. office in Riverhead. Terms Acceptance* I agree to the Terms & Conditions outline above Signature of Parent or Guardian*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Promo CodeThe Bookkeeping Department will apply any promotional discount to your total bill. Please call Bookkeeping if you have any questions.How would you like to leave your $500 deposit?*Pay by credit card onlineMail a checkIn order to complete your registration, please submit this form and then mail a check to: Park Shore Country Day Camp 450 Deer Park Road Dix Hills, NY 11746 Attn: BookkeepingPay deposit by credit card Price: $500.00 Total $0.00 Name on Credit Card*Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Visit Us 450 Deer Park Road Dix Hills, NY 11746 Contact us 631.499.8580 info@parkshoredaycamp.com Tour Hours M-F: 10am - 4pm S-S: 11am - 2pm (February - June) Learn More About Extreme STEAM Science Kids Learn More About Park Shore Country Day School FollowFollowFollow Learn More About Park Shore Perks