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Purchase Day Camp 2017 Little Sprouts Enrollment Application

Fill out the application below and click "Recalculate Total" at the bottom of the form to continue.


Camper's Last: First: Birthdate: Age (on 7/1/17):

Street: City: State: Zip: Home Phone: ()-

Gender: Grade 2017-18: School 2017-18:

Special Placement Requests: Camper/Friend:

Allergies, Medical Conditions, or Special Needs if any?

Choose Which Week(s) You Want - Check Each Week Requested
June 5-9
June 12-16
June 19-23
Choose How
Many Weeks
Little Sprouts Mini Camp 2017 Fees
Discounted Fees for Enrolled 2017 Purchase Day Campers
Program
Mini Day (9am-1pm)
Full Day (9am-3pm)
Mini Day (9am-1pm)
Full Day (9am-3pm)
1 Week
2 Weeks
3 Weeks



Mother or Guardian Contact Information:




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Father or Guardian Contact Information:



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Total: $2025

A $750 deposit is required with this application.




3095 Purchase Street • Purchase, NY 10577 • Tel. 914-949-2636 • Fax. 914-949-0955
office@purchasehouse.com