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Discovery Application Summer 2024
Please fill out the following application to register for the Bethpage Summer Discovery Program! If you have more than one child attending the program, please fill out an application for each child. Once payment is received you will receive a confirmation email that your registration is complete. Please enter the email address you wish to be contacted with below:
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* Indicates required question
Email
*
Your email
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Birth Date
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Prefer not to say
Other:
Grade Entering September 2024 (This coming school year!)
*
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Required
School
*
Charles Campagne
Kramer Lane
Central Boulevard
JFK Middle School
Other:
Required
Guardian One Name
*
Your answer
Guardian One Relationship
*
Your answer
Guardian One Cell Phone Number
*
Your answer
Guardian Two Name (Optional)
Your answer
Guardian Two Relationship
Your answer
Guardian Two Cell Phone Number
Your answer
Home Address: Number and Street Name
*
Your answer
Town
*
Your answer
Zipcode
*
Your answer
Home Phone Number
*
Your answer
Emergency Contact 1 Name
*
Your answer
Emergency Contact 1 Relationship
*
Your answer
Emergency Contact 1 Phone Number
*
Your answer
Emergency Contact 2 Name
*
Your answer
Emergency Contact 2 Relationship
*
Your answer
Emergency Contact 2 Phone Number
*
Your answer
Physician Name
*
Your answer
Physician Phone Number
*
Your answer
Does your child have any allergies or dietary restrictions?
*
Yes
No
If yes to the above question, please specify
Your answer
Does your child require medication on a daily basis?
*
Yes
No
If yes to the above question, please specify
Your answer
** We need a Doctor's Prescription for the Nurse to administer any medication ** Please email note to
bethpagesummerdiscovery@gmail.com
or bring with child on the first day of the program.
Does your child have any medical/health concerns?
*
Yes
No
If yes to the above question, please specify
Your answer
Is your child restricted from any physical activity?
*
Yes
No
If yes to the above question, please specify
Your answer
Has your child had any serious illness, injury, or operation?
*
Yes
No
If yes to the above question, please specify
Your answer
My child can be picked up by... (Please list all individuals that are allowed to pick up this child. For example the grandparent, aunt, babysitter, neighbor. Please provide name and relationship)
*
Your answer
My child CANNOT be picked up by (list all that apply)
Your answer
Pictures: My child can/cannot be photographed during the summer program for purposes of publicity and to place on Our Discovery Program website.
*
Yes, my child can be photgraphed
No, I do not want my child photgraphed
If possible, my child would like to be in the same class as: **We cannot guarantee all preferences**
Your answer
EACH child will be $450 for Summer 2024. Payment can be made by CHECK ONLY. You will receive an email confirmation to the email you first listed above once registration is complete. NO REFUNDS WILL BE GIVEN. NO EXCEPTIONS.
Checks should be made payable to Bethpage Discovery Program.
Mail check to:
Bethpage Discovery Program
18 Keswick Lane
Plainview, NY 11803.
Please clearly write child's name in the memo so that we can confirm the receipt.
Please feel free to email
bethpagesummerdiscovery@gmail.com
with additional questions!
A copy of your responses will be emailed to the address you provided.
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