Park Shore Information Request

What Program(s) Are You Interested In?*
Day Camp
Flexible Day Camp
Travel Camp Programs (Grades 6-9)
Toddler Day Camp Program
Extreme STEAM Science Kids Camp
Sports Track
Preschool School Program
Kindergarten
Toddler School Program
Extreme STEAM Science Kids After School or Weekend Program
Preschool & Kindergarten After School Programs

Contact Information

First Name*

Last Name*

Email*

Place of Work*

Mobile Phone*

Home Phone

Address*
Street Address Address Line 2 City State ZIP Code

Child 1 Information

Child 1 Name

Child 1 Birthdate

Grade Completed as of Coming June

Child 2 Information

Child 2 Name

Child 2 Birthdate

Grade Completed as of Coming June

Child 3 Information

Child 3 Name

Child 3 Birthdate

Grade Completed as of Coming June

Additional Information

How did you hear about us? Please check all that apply.*
Google
Facebook
Instagram
Yelp
LongIsland.com
Mommy Poppins
Long Island Parent
Macaroni Kid
Living Huntington
Advertisement
Through your place of work
Friend/Relative
Park Shore Employee
Drove by
Other

If "Other," Please Specify

Name of Company

Recommended by

Additional Comments or Questions

Name
This field is for validation purposes and should be left unchanged.

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