QUEENS COLLEGE SUMMER CAMP APPLICATION:

Please fill out and Mail or Fax to:

Queens College Summer Camp 2013, 65-30 Kissena Blvd, Flushing, NY 11367-1597

Fax: 718-997-2768 or Phone 718-997-2777

Child's Name:________________________________________________

 

Sex ________Date of Birth ____________ Age at Camp Time___________________

 

Mother's Name: ______________________________ Cell Phone #: __________________

 

Father's Name: ______________________________ Cell Phone #: ___________________

 

Address___________________________________________________ Apt # _______

 

City___________________________________State___________Zip______________

 

Home Phone #___________________ Work Phone #____________________

 

E-mail address ______________________________________________________________

 

Has your child ever attended the QC Summer Program   ___ Yes   ___ No

***Does your child receive special accommodations during the school year? If Yes, Please explain?

___________________________________________________________________

WHERE DID YOU HEAR ABOUT US?

 ___Flier                   ____Newspaper/Magazine, which? __________________

 ___PTA newspaper           ____Word of mouth

 ___Direct mail             ____Website, which? ________________________

 

Tuition                         $ _______

                                     - Deposit of $250   Registration Fee is Non-refundable after April 1    

 

Kosher Lunch             +$ ________  ($50.00 per week)

Balance (Due April 1st)$ ________

 

If registering after April 1, Balance due upon receipt of bill

FORM OF PAYMENT  ___Check/Money Order   ____ Visa    _____ MC  _____ Discover

Account # ___________________________________ Exp. Date ______3 digit code: _____

Cardholders’ Name ___________________________________________________________

Signature ___________________________________________________________________

UNION MEMBER SIGNATURE:

 _____________________________________________________

(Program Information Please indicate your program choices below.

Kosher Lunch ____ Yes  ____NO ($50 a week)

T-Shirt Size (circle one) Child’s S(6-8) M(10-12) L(14-16),Adult: S  M  L XL

Program Information

QC Education & Sports Program Session Dates 

Circle total number of weeks attending:   2,   4,   6,  or   8 weeks

Complete section below

Please select in order of preference 

July 1 - July 26 - First 4 weeks

        Section A class codes    Section B class codes    Section C Sports Codes

 

    1^st choice ___________    1^st choice __________     1^st choice ____________

 

    2^nd choice ___________    2^nd choice __________     2^nd choice ____________

 

July 29 - August 23 - 2 or 4 weeks

 

    Section A class codes    Section B class codes    Section C Sports Codes

 

    1^st choice __________     1^st choice __________     1^st choice ____________

 

    2^nd choice __________     2^nd choice __________     2^nd choice ____________

Theater Production  

Session Code C July 1-July 26 First 4 weeks   Code#__________

Session Code D July 29-August 23 Last 4 weeks  Code#__________

 

Sports Academy Session Dates

Circle one session date code: A   B   C   D   E   F   G   H   I  

 Reg. Code #

 1^st choice ___________

 2^nd choice  ___________                                          

You can download the application and fax or mail it or call us and we can register over the phone.