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Park Shore Request for Information

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Park Shore Information Request
Full Day Camp Program		Sports Track Program
Super Senior Program		Toddler Camp Program
Explorer Travel Program		Flexible Camp Program
SuperTeen Travel Program		Pre-School Program

Contact Information
First Name :
Last Name :
Email :
Phone :
Mobile :
Work Phone :
Work Email :
Street :
City :
State :
Zip Code :
Child 1 Information
Child 1 Name
Child 1 Birthdate (MM/DD/YYYY)
Grade Completed as of Coming June
Child 2 Information
Child 2 Name :
Child 2 Birthdate (MM/DD/YYYY)
Grade Completed as of Coming June - Chilld 2 :
Child 3 Information
Child 3 Name
Child 2 Birthdate (MM/DD/YYYY)
Grade Completed as of Coming June
Additional Information
how did you hear about us?
If other, friend or relative, please specify: :
Enter Any Additional Comments and/or Information or Promo Codes Here:

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For Boys and Girls Ages 2 - 14

450 Deer Park Road
Dix Hills, Long Island New York 11746
Phone: 631.499.8580 · Fax: 631.499.6917