2021 Toddler Enrollment Form: Early Rates CAMPER INFORMATIONName* 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*MaleFemaleSchool Attended 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 OptionsClick 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 For Your ChildPlease Choose How Many Weeks Your Child Will Be Attending:*Eight WeeksSix WeeksFour WeeksTwo WeeksUndecidedIf you are undecided on how many or what weeks your child will be attending, please let us know in the Custom Session Box below. If you would like to see the pricing, please click on 8, 6, 4 or 2 weeks to see the pricing. You can still enroll without choosing your weeks or days.Please Choose a Session:*Session 1 (6/28 - 7/23)Session 2 (7/26 - 8/20)UndecidedPlease Choose Six One-Week Sessions:* 6/28 - 7/2 7/6 - 7/9 7/12 - 7/16 7/19 - 7/23 7/26 - 7/30 8/2 - 8/6 8/9 - 8/13 8/16 - 8/20 Undecided Please Choose One Two-Week Session:* 6/28 - 7/9 7/12 - 7/23 7/26 - 8/6 8/9 - 8/20 Undecided How Many Days a Week Will Your Child Attend?*5 Days: Eight Week Toddler: $21804 Days: Eight Week Toddler: $19253 Days: Eight Week Toddler: $16902 Days: Eight Week Toddler: $1125UndecidedIf you are undecided on how many or what days your child will be attending, please let us know in the Custom Session Box below.How Many Days a Week Will Your Child Attend?*5 Days: Six Week Toddler: $16904 Days: Six Week Toddler: $15153 Days: Six Week Toddler: $13352 Days: Six Week Toddler: $890UndecidedIf you are undecided on how many or what days your child will be attending, please let us know in the Custom Session Box below.How Many Days a Week Will Your Child Attend?*5 Days: Four Week Toddler: $11954 Days: Four Week Toddler: $10953 Days: Four Week Toddler: $9952 Days: Four Week Toddler: $660UndecidedIf you are undecided on how many or what days your child will be attending, please let us know in the Custom Session Box below.How Many Days a Week Will Your Child Attend?*5 Days: Two Week Toddler: $6604 Days: Two Week Toddler: $5953 Days: Two Week Toddler: $5602 Days: Two Week Toddler: $340UndecidedIf you are undecided on how many or what days your child will be attending, please let us know in the Custom Session Box below.Please Choose What Days for Your Child will be Attending MON. TUES. WED. THURS. FRI. Would you like transportation? (if available to your area)*Yes: $300NoWould you like transportation? (if available to your area)*Yes: $250NoWould you like transportation? (if available to your area)*Yes: $200NoWould you like transportation? (if available to your area)*Yes: $135NoWould you like transportation? (if available to your area)*YesNoWould you like transportation? (if available to your area)*Yes: $225NoWould you like transportation? (if available to your area)*Yes: $200NoWould you like transportation? (if available to your area)*Yes: $150NoWould you like transportation? (if available to your area)*Yes: $100NoWould you like transportation? (if available to your area)*YesNoWould you like transportation? (if available to your area)*Yes: $150NoWould you like transportation? (if available to your area)*Yes: $125NoWould you like transportation? (if available to your area)*Yes: $100NoWould you like transportation? (if available to your area)*Yes: $70NoWould you like transportation? (if available to your area)*YesNoWould you like transportation? (if available to your area)*Yes: $90NoWould you like transportation? (if available to your area)*Yes: $70NoWould you like transportation? (if available to your area)*Yes: $50NoWould you like transportation? (if available to your area)*Yes: $35NoWould you like transportation? (if available to your area)*YesNoIf you can't find a session that suits your exact needs, please describe what you're looking for here and we'll try to accommodate you. If needed, also include any concerns or questions.Custom Session I would like my child to be in the same group as:Camper #1Camper #2How 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 Attends/Attended Park Shore Day School Attended Rookie Day Attended free class at Extreme STEAM Science Friend/Relative Park Shore Employee Place of work Drove by Other Recommended by:CompanyOtherTERMS & CONDITIONSTo 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. Tuition includes snack, lunch, and camp pictures. Toddlers are to be transported by their parent or guardian. Transportation may be available upon request. A $100 deposit is payable at the time of enrollment and will be credited towards the balance. The balance of all tuitions is due no later than Friday, April 16, 2021 and represents the total cost of the Summer Toddler Program. You can pay with check, credit card, or cash. If you decide to use a credit card, we must have a credit card authorization form on file. 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. It is understood that all photography and video photography taken at camp may be used for promotional purposes, as well as for projects. Due to a limited group size, enrollment is on a first come basis. 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. 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 Outlined Above Signature of Parent or Guardian*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How Would You Like to Leave Your $100 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: $100.00 Total $0.00 Name on Credit Card*Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name EmailThis 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