PHCC Summer Camp Enrollment Form 2024

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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. We will be offering various presenters, indoor/outdoor games, and enrichment activities. Camp will be held on MONDAYS, TUESDAYS, and WEDNESDAYS from 9am to 3pm at the Pine Hill Community Center, 287 Main St, Pine Hill NY. Please send your camper with comfortable footwear, a bag lunch, and a water bottle.

Location: 287 Main St, Pine Hill NY
Start Date: Monday July 15th
End Date: Wednesday Aug 21st
Time: 9am-3pm (you are responsible for your child's prompt pick up and drop off)
Eligible Ages: 5-10

PLEASE NOTE:

Your child is not guaranteed a spot. Due to budget concerns and the success of our campers we can only offer summer camp to 25 campers this year. We will let you know by June 1st if your camper has been accepted.

Please contact cmcmurray@pinehillcommunitycenter.org with any questions or concerns.

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 *

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

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 list an other camps your child will be attending this summer.

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. Please feel free to include any of their favorite activities or hobbies. *

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

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