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Nassau County
On-Line Pre-Enrollment Form!
  Brendan McCaffrey
Director
Steve Restevo
Assistant Director
Michelle Baloga
Camp Manager 		Phone
516.650.1856
   
 

OnLine Pre-Enrollment Form
 Phone 516.650.1856 Ans.Service 631.476.3330
 Email bmccaffrey@lycos.com
   
  Pre-Enrollment Sign Up Form!
 

Parents/Guardian Information

 
First Name:
 
Last Name:
 
Address:
 
City:
 
State/County:
 
Cell Phone#
 
Zip Code
 
Home Phone#
 
Work Phone#
 
E-Mail
 

 
 
Credit Information
 For Enrollment Deposit of $100.00
  
Credit Card
 
Name
 
Card #
 
 
Month          Year
  
Number of Weeks
 
     
 
Child's Information
  
Name:
 
Birthdate:
 
Grade/Fall:
 
Address:
 

Child # 2 Information

  
Name:
 
Birthdate:
 
Grade/Fall:
 
Address:
 

Child # 3 Information

  
Name:
 
Birthdate:
 
Grade/Fall:
 
Address:
 

Additional Comments and/or Information

  
Comments: