Enroll Now For the 2021-2022 School Year! Contact Us STUDENT INFORMATIONName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Phone #Email* Gender* Male Female PARENT INFORMATIONParent's Name* First Last Bus. Phone #Cell #*Address (If Different From Student's Address) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 2 Name (Optional) First Last Bus. PhoneCell #Address (If Different From Student's Address) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMERGENCY CONTACTS Name:* Relationship:* Phone*Name: Relationship: Phone*** Yearly tuition of 10 equal payments based on the session & lunch preference you select *** Please Select a Program* Pre-School / Toddler - 5 Days Pre-School / Toddler - 4 Days Pre-School / Toddler - 3 Days Pre-School / Toddler - 2 Days Kindergarten - 5 Days Select a 5-Day Session* MORNING 9:00am–12:00pm: $945 MORNING/MID 9:00am-2:00pm: $1295 FULL DAY 9:00am–3:30pm: $1495 Add Lunch ($135 Additional)* Yes No Select a 4-Day Session* MORNING 9:00am–12:00pm $850 MORNING/MID 9:00am-2:00pm $1115 FULL DAY 9:00am–3:30pm $1320 Add Lunch ($120 Additional)* Yes No Select a 3-Day Session* MORNING 9:00am–12:00pm $745 MORNING/MID 9:00am-2:00pm $1020 FULL DAY 9:00am–3:30pm $1140 Add Lunch ($110 Additional)* Yes No Select a 2-Day Session* MORNING 9:00am–12:00pm $565 MORNING/MID 9:00am-2:00pm $775 FULL DAY 9:00am–3:30pm $880 Add Lunch ($75 Additional)* Yes No Kindergarten* FULL DAY 9:00am–3:30pm $1495 Add Lunch ($135 Additional)* Yes No Please Select Which Days You Would Like Your Child to Attend Monday Tuesday Wednesday Thursday Friday We are also happy to offer our families an Extended Day Program for those who require it. If you choose to utilize Before and AfterCare, payment is as follows*: 5 Days: $150 per monthly payment, 4 Days: $120 per monthly payment, 3 Days: $90 per monthly payment, 2 Days: $60 per monthly payment. If you only require Before OR AfterCare, the payment is half of the amount stated above. Do you require Before or After Care?* Yes No I require:* Before Care After Care Before and After Care Drop-off time:* Before Care runs from 7:00am-8:45am. Breakfast is served at 8:00amPick-up time:* After Care runs from 3:45pm-5:00pmComments or questions:How did you hear about us? Please check all that apply.* Google Facebook Instagram Yelp Advertisement Mommy Poppins Long Island Parent Living Huntington Macaroni Kid LongIsland.com Free Event at Park Shore Friend/Relative Employee Attends/Attended Park Shore Day Camp Place of Work Drove by Other Recommended by: Company name Other: TERMS AND CONDITIONS There is a 3% administrative fee on all tuition payments. You can pay with check, cash or credit card. If you pay by cash or check Park Shore will waive this 3% fee. Tuition includes school pictures and supplies. The yearly tuition is based on 10 equal payments of the session and lunch preference you selected on the front of this enrollment contract. If you require Before and/or Aftercare, there is an additional monthly payment based on the number of days you attend. The yearly school tuition does not include our two week pre-camp program. A $200 deposit is payable at the time of enrollment and will be credited towards the first payment. This deposit is refundable until June 4, 2021. No refunds will be made after June 4, 2021. You can pay with check, credit card, or cash. If you decide to use credit card, we must have a credit card authorization form on file. The balance of your first payment will be due August 6, 2021. Nine additional payments are due by the 1st of each month ending on May 7, 2022. It is understood that no refunds or substituting of days will be made for school closings, holidays, sickness, cancellations or quarantine. Park Shore reserves the right to terminate this agreement at any time for any reason and will refund the tuition on a pro-rata basis. A medical form, completed by your child’s doctor, must be on file before your child’s session begins. In the event of any emergency in which the parent cannot be contacted, the directors reserve the right and are hereby authorized to have your child hospitalized, or to use outside medical, surgical, or dental aid. I authorize any physician, nurse, or other healthcare provider, to communicate with the directors of Park Shore Country Day School, or his/her designee about my child’s medical condition, treatment, and/or prognosis. I hereby grant permission to use any photograph, film or other image for promotional purposes, including but not limited to brochures, DVD’s, our website and Facebook page and other on-line postings. In the event Park Shore has to close due to New York State mandates, Park Shore will switch to our Virtual Long Distance Learning Program during the closure for the remainder of the month’s cycle. There will be no refunds or make-up time for the time lost. If we have to close for longer than a month Park Shore’s Virtual Long Distance Learning Program will be available for a monthly tuition of $200.00. This program will be available five (5) days a week. Binding Arbitration – I agree that any dispute concerning, relating, arising out of or referring to the subject matter of this contract shall be resolved exclusively by binding arbitration in Suffolk County, New York, according to the then existing commercial rules of the American Arbitration Association and the substantive laws of the state of New York. Terms Acceptance* I agree to the Terms & Conditions Outlined Above Signature* Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Promo Code The Bookkeeping Department will apply any promotional discount to your total bill. Please call Bookkeeping if you have any questions.Do You Want Paperless Billing?* Yes No How Would You Like to Leave Your $200 Deposit?* Pay by Credit Card Online Mail a Check In order to complete the enrollment process, please click Submit and then mail a check to: Park Shore Country Day Camp & School 450 Deer Park Road Dix Hills, NY 11746 Attn: BookkeepingDeposit* Price: Total $0.00 Name on Credit Card* Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Visit Us 450 Deer Park Road Dix Hills, NY 11746 Contact us 631.499.8580 info@parkshoredayschool.com Tour Hours M-F: 10am - 3pm S-S: 11am - 2pm (February - June) Learn More About Park Shore Country Day Camp learn more about Extreme STEAM Science Kids learn more about Park Shore Perks FollowFollowFollow