Park Shore Request for Information

Park Shore Information Request


Full Day Camp Program:		Toddler Camp Program:
Super Senior Program:		Flexible Camp Program:
Explorer Travel Program:		Pre-School Program:
SuperTeen Travel Program:
Sports Track Program:


First Name:
Last Name:
Street:
City:
State:
Zip Code:
Email:
Phone:
Mobile:
Work Phone:
Work Email:


Child 1 Name:
Child 1 Birthdate:		MM/dd/yyyy
Grade Completed as of Coming June:


Child 2 Name:
Child 2 Birthdate:		MM/dd/yyyy
Grade Completed as of Coming June:


Child 3 Name:
Child 3 Birthdate:
Grade Completed as of Coming:


How did you hear about us?
If other, friend or relative, please specify:
Additional Comments and/or Information:

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