PHCC Summer Camp Enrollment Form 2021

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Finally, back from a long break, Pine Hill Community Center's Summer Camp for kids is back! We are excited to offer children a safe, structured, and fun environment to gather, learn, and explore this summer. In collaboration with Morton Memorial Library we will be offering various presenters and indoor/outdoor games and activities. Camp will be held on MONDAYS and TUESDAYS from 10am to 3pm at the Pine Hill Community Center, 287 Main St, Pine Hill NY. We will be strictly following all COVID-19 guidelines for NYS schools (masks and 6ft distancing).

Location: 287 Main St, Pine Hill NY
Start Date: Monday June 28th
End Date: Tuesday Aug 3rd
Time: 10am-3pm (you are responsible for your child's prompt pick up and drop off)
Eligible Ages: 5-15

Email *

Child's Name *

Child's Date of Birth *

YYYY

Primary Address *

Caregiver Name *

Relationship to Child *

Caregiver Address *

Caregiver Home/Cell/Work Phone *

Emergency Person #1 (These should be local persons who may be notified in case of emergency or illness) *

Emergency Person #1 Relationship to Child *

Emergency Person #1 Contact Phone *

Can child be released to Emergency Contact # 1 *

Yes

Emergency Person #2 (These should be local persons who may be notified in case of emergency or illness)

Emergency Person #2 Relationship to Child

Emergency Person #2 Contact Phone

Can child be released to Emergency Contact # 2

Yes

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Please list any allergies (food, medication, bees, etc.) *

Please list any other medical concerns our program should be aware of *

We want all of our youth to be safe and healthy. Does your child meet minimum vaccine requirements needed to attend school? (polio, Hep B, Diphtheria/Tetanus/Pertussis, Measles/Mumps/Rubella, Chickenpox, does not include COVID-19 vaccine) *

Yes

RELEASE FORM: Do you give consent for your child to appear in any media approved by The Pine Hill Community Center Summer Camp *

Yes

RELEASE FORM: Do you give consent for your child to leave The Pine Hill Community Center with staff to visit the park , library, go for hike/walks, etc? *

Yes

RELEASE FORM: If yes, to either of the above, please list any restrictions for media or travel *

Please provide us with any additional details about your child that may be relevant for us to know in order for us to provide them with a safe, enriching, and fun summer *

Caregiver Electronic Signature (Please type your full name below) *

Submit

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