Buckley Country Day Camp, Enroll Now, Long Island summer camp

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Buckley Country Day

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Family Information

Home Phone #*

Mother's Name*

Mother's Work/Cell*

Father's Name*

Father's Work/Cell*

Street Address (where the bus will pick up and drop off.)*

City*

State*

Zip*

Main Contact Information

Please provide (only) ONE email address and the best ONE phone number that we can use to contact you before and during camp.

Main Contact Email Address*

Secondary Email

Main Contact Primary Phone Number*

Emergency Contact Information

Emergency Contact Name (other than parents)*

Relationship*

Emergency Contact Phone number*

Camper Programs

Mini Day 9:00 - 1:00 p.m. (entering N - K). Child must be 3 years by 9/1/07.

Full Day 9:00 - 4:00 p.m., Child must be entering Pre-K - 7th grade and "Teen Campers" 8th Grade.

Counselor In Training 9:00 - 4:00 p.m. Child must be entering 9th - 11th grade.

Child 1

Name*

Date of Birth*

Gender*

	Female
	Male

Age as of 7/1/10*

Grade (next September)*

Number of Years at Buckley (including this summer)*

Requires bus transportation?*

	Yes
	No

Camper Program - session/date*

	Mini Day – 8 weeks (6/29-8/20) - $6320
	Mini Day – 6 weeks (6/29-8/06) - $5710
	Mini Day – 6 weeks (7/12-8/20) - $5710
	Mini Day – 4 weeks (6/29-7/23) - $4650
	Mini Day – 4 weeks (7/26-8/20) - $4650
	Full Day – 8 weeks (6/29-8/20) - $6800
	Full Day – 6 weeks (6/29-8/06) - $6070
	Full Day – 6 weeks (7/12-8/20) - $6070
	Full Day – 4 weeks (6/29-7/23) - $5130
	Full Day – 4 weeks (7/26-8/20) - $5130
	CIT – 8 weeks (6/29-8/20) - $5720
	CIT – 6 weeks (6/29-8/06) - $5130
	CIT – 6 weeks (7/12-8/20) - $5130
	CIT – 4 weeks (6/29-7/23) - $4200
	CIT – 4 weeks (7/26-8/20) - $4200

Child 2

Name

Date of Birth

Gender

	Female
	Male

Age as of 7/1/10

Grade (next September)

Number of Years at Buckley (including this summer)

Requires bus transportation?

	Yes
	No

Camper Program - session/date

	Mini Day – 8 weeks (6/29-8/20) - $6320
	Mini Day – 6 weeks (6/29-8/06) - $5710
	Mini Day – 6 weeks (7/12-8/20) - $5710
	Mini Day – 4 weeks (6/29-7/23) - $4650
	Mini Day – 4 weeks (7/26-8/20) - $4650
	Full Day – 8 weeks (6/29-8/20) - $6800
	Full Day – 6 weeks (6/29-8/06) - $6070
	Full Day – 6 weeks (7/12-8/20) - $6070
	Full Day – 4 weeks (6/29-7/23) - $5130
	Full Day – 4 weeks (7/26-8/20) - $5130
	CIT – 8 weeks (6/29-8/20) - $5720
	CIT – 6 weeks (6/29-8/06) - $5130
	CIT – 6 weeks (7/12-8/20) - $5130
	CIT – 4 weeks (6/29-7/23) - $4200
	CIT – 4 weeks (7/26-8/20) - $4200

Child 3

Name

Date of Birth

Gender

	Female
	Male

Age as of 7/1/10

Grade (next September)

Number of Years at Buckley (including this summer)

Requires bus transportation?

	Yes
	No

Camper Program - session/date

	Mini Day – 8 weeks (6/29-8/20) - $6320
	Mini Day – 6 weeks (6/29-8/06) - $5710
	Mini Day – 6 weeks (7/12-8/20) - $5710
	Mini Day – 4 weeks (6/29-7/23) - $4650
	Mini Day – 4 weeks (7/26-8/20) - $4650
	Full Day – 8 weeks (6/29-8/20) - $6800
	Full Day – 6 weeks (6/29-8/06) - $6070
	Full Day – 6 weeks (7/12-8/20) - $6070
	Full Day – 4 weeks (6/29-7/23) - $5130
	Full Day – 4 weeks (7/26-8/20) - $5130
	CIT – 8 weeks (6/29-8/20) - $5720
	CIT – 6 weeks (6/29-8/06) - $5130
	CIT – 6 weeks (7/12-8/20) - $5130
	CIT – 4 weeks (6/29-7/23) - $4200
	CIT – 4 weeks (7/26-8/20) - $4200

Sibling Discount

2nd Child 10%, 3rd Child 15%, 4th Child (+) 20%

Deposit Information

A $500 deposit, per camper is required for enrollment. Your deposit is 100% refundable until April 1st.

Cardholder’s Name:
Credit Card Type:
Card Number:
Expiration Date:

Terms of Agreement

• I understand that the $500 deposit will be paid upon enrollment and my full balance is due by May 15, 2010.

• Should it be necessary for any reason to change enrollment or withdraw from the camp (I must make this request in writing.) - Before April 1, 2010 my $500 deposit will be fully refunded. - After April 1st but before May 15, 2010, my tuition including deposit will be refunded minus a $100 processing fee. - After May 15, 2010, my child’s tuition including deposit will not be refunded.

• There are no refunds for absences unless for medical reasons for 5 or more consecutive days, a pro-rated refund will be made. A Physician’s note must be submitted.

• Buckley Camp reserves the right to terminate a child’s enrollment for any reason pertaining to the safety and welfare of all campers.

• For each child that does not require bus transportation, I understand that I will receive a transportation discount of $40 per week.

• Transportation changes must be in writing by May 1, 2010.

• I understand a current Health Form and Emergency Release form must be on file at Buckley Camp by June 1, 2010.

• I hereby give permission for photographs of my child to be taken and used for promotional uses.

• I understand that I am responsible for the balance of my tuition and my credit card will be billed for any final outstanding balances on May 15th.

I accept the Terms of Agreement*

Yes

Date*

If you would like a copy of this submission, please put your email address in the field below.

Please Note: Questions marked with an asterisk (*) are required.