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Program Registration Form#
Summer 2015 Registration On-line/By Mail
Will be available March 2015
It is required that you and your child meet with one of our staff prior to registration for an IFA (Initial Family Assessment) if you are new to the Center. This will alleviate any anxiety or unsure feelings about enrolling and it will help include them in the decision.
Registration Fees are non-refundable
Immunization Records MUST be received to guarantee enrollment
1.Print form below, fill out one for each child and sign all spaces (please read thoroughly).
2. Mail with a non-refundable deposit (check or money order) in the amount of $25.00, and payment towards the first week to Sunshine Center in order to hold your spot (See address in contact section). CAMP MUST BE PAID PRIOR TO STARTING!
3. Call a few days later to confirm that Sunshine got your form in the mail (Sunshine is not responsible for lost or misdirected mail).
4. An invoice will be sent to you for the balance with a confirmation.
5. Deposits will only be returned if the program is full, unless you want to be put on the waiting list.
6. Programs usually fill to full capacity with a waiting list. No mail-in registrations are guaranteed until you are notified by Sunshine.
7. Sunshine will contact you if further information is needed for registration
Asking for financial assistance/sponsorships?
You must fill out the paperwork—click here for form—
no spot is guaranteed—sponsorships are limited based on funding
Sunshine Summer Prevention Program Registration Form - 2015
468 Boyle Road, Port Jeff Station, NY 11776 * Phone: (631) 476-3099, Fax: (631) 476-7680
Date __________________ How did you find out about this program? _________________________
Name of Participant___________________________________________ Birth date ___________________
Male / Female Grade Completed ________ School ________________ Age in summer _________
Race/ethnicity: Black ____ White ____ Hispanic ____ Native American _____ Asian _____ Other __
Parent(s)/Guardian(s) ___________________________________ Home Phone_________________
Mailing Address _______________________________________________ Cell Phone_________________
Town, Zip ___________________________________________ Work Phone_________________________
Emergency Contact ____________________Phone_______________Alternate Phone___________
Email Address (For Invoicing, program Information, newsletters)__________________________________
Social Skill Youth Camp Ages 4—11
Please check sessions you are registering your child for:
Check weeks you are registering this child for _______ Children 4—11 _______ CIT Program ages 12 & up
____ Week 1: July 6 – 10 ____ Week 2: July 13 - 17 ____ Week 3 July 20 - 24
____ Week 4: July 27 – 31
Total Weeks you are registering for Social Skills Youth camp ________
Life Skills Teen Camp ages 12 and up
Check weeks you are registering this child for _______ Youth ages 12 & up _______ Preteen program 10 & 11
____ Week 1: August 3 - 7 ____ Week 2: August 10 - 14 ____ Week 3 August 17 - 21
Total Weeks you are registering for Life Skills Teen Camp ________
I understand that if my child has been registered for the Summer Program, the space will be reserved for my child. Spaces are limited for every program run through Sunshine Center. If you reserve a space for your child, that eliminates the opportunity for another child to come. There is a $25 non-refundable registration fee required for all participants in all programs. If you have registered and want to switch programs/weeks for some reason, Sunshine cannot guarantee this unless there are open spaces. If you have registered and paid for your child and then you need to take your child out of the program for some reason you must give us two weeks notice in order for you to receive a refund. If you do not notify us, you will be responsible to pay for the whole program in full. I understand and I am aware there is a no-refund policy. _______ initial
I understand in the case of an emergency or a medical problem, Sunshine Center will do their best to reach me. I give my permission for my emergency contacts and said physicians to make medical decisions that are in the best interest of the said child. I understand if the representatives of the Sunshine Center are unable to reach me, my family, my physician, or my emergency contacts, I give permission to the medical personnel elected by the program director to follow any procedures necessary for the safety and well being of my child. _______ initial
I give my child permission to engage in all program activities including games, lunches/snacks, field trips, lessons. I understand that my child MAY be attending a program at the Old Town Equestrian Center which is located across the street and will be under full supervision at all times (Only specified weeks). I understand that the children may walk to Boyle Road School next door to the Center to engage in large group recreation activities. They will be supervised by staff members at all times. ________ initial
I understand my child MAY be participating in pre & post tests and evaluations to monitor the success and effectiveness of this program. (Specific child’s name/participation is confidential) ________ initial
I understand that any group or program my child attends is not considered therapy or treatment. While I expect benefits from this program, I fully understand that no particular outcome can be guaranteed. I understand I am free to take my child out of the program, but that it would be in the best interest of all to talk with the facilitators and directors first. _______ initial
I understand that there may be photographs taken or stories done on the Center. Photographs are taken for promotional purposes. Stories are done periodically on the Center and the valuable services it offers through radio, TV, and press. If the center is represented in the media, it is recognized as a prevention center, providing youth with a safe environment, positive role models, and alternative activities to alcohol, drugs, and violence. Grants and funding are provided for economically disadvantaged families or children at-risk. Sometimes this information is recognized in the media reports. Please make the center aware if you do not want your child involved in any photographs or media reports. ________ initial
I understand there are basic rules and guidelines that my child must follow. I agree to review the basic rules and guidelines with my child. I understand these rules and guidelines will be reviewed with my child during the program. I understand that if for some reason this program or group is not suitable for my child or the other participants, Sunshine Center will follow the necessary steps as explained in the rules and guidelines. ________ initial
Where as, The Sunshine Center, Inc., also know as Sunshine Prevention Center for Youth & Families, with its principal place of business located at 468 Boyle Road, Port Jefferson Station, NY 11776, will operate a summer program on the said premises, which is owned by the Town of Brookhaven but leased to Sunshine Center, Inc.
Whereas, the undersigned parent/guardian has enrolled (child’s name)________________________ Residing at (address) __________________________________________________ to participate in the said program and to take part in the activities offered during the Summer Programs by Sunshine Center, Inc.
This agreement is in effect from June 30, 2012 through September 1, 2012.
Signed _____________________________________ Print name__________________________________ Date ________________
Parent/Guardian of (child’s name)________________________________________________________________________________
*** YOU MUST PAY IN FULL ONE MONTH PRIOR TO THE START OF THE PROGRAM! ***
Immunization Records are required for ALL participants*
Has your child had a history of any illnesses? Explain__________________________________
Is your child currently taking medicine? _____ Type/For what_____________________________
Does your child have any allergies (food, medicine, etc.)? _____ Explain_____________________
Does your child have any special dietary needs? _____ Explain ____________________________
You must provide your own lunch – We may provide some snacks for the children
Child’s Doctor ______________________ Phone Number ________________
Child’s Dentist ___________________________ Phone Number ___________________________
Sunshine’s Child Assessment Form – Summer 2015
Filling out this form is optional. The information on this form will help Sunshine to understand your child’s needs and assist us in the development and delivery of successful prevention programs. All information on this form will be kept completely confidential and will only be accessible to the appropriate staff.
Child’s Name _________________________ Age______ Grade in September__________ DOB_________________
Your relation to child: Biological parent _____ Step parent _____ Grandparent _____ Adoptive parent _____ Foster parent _____ Relative _____ Other _____ (explain)______________
What attracted you to this program?___________________________________________________________________
What are you hoping for your child to get out of this program?______________________________________________
Family Makeup (Who lives within your household, such as two parents, siblings, etc)______________________________________
Please list any family factors that may be affecting your child (e.g. divorce, trauma, abuse, loss) __________________
Please list any illness, disability, or diagnosis (physical, developmental, mental) that you want to make us aware of ________________________________________________________________________________________________
Please list any behavior challenges or situations you want to make us aware of (Anxiety, aggressive behaviors, etc) ________________________________________________________________________________________________
How does your child relate in social situations?_________________________________________________
How does your child express feelings/anger?_______________________________________________________________________
Please describe the best things about your child _____________________________________________________________________
Please list any specific concerns you have with your child ________________________________________________
Rate your child’s self esteem Low ________ Average _________ High________
Has your child had any academic or other problems in school? ______ Please explain __________________
Does your child tend to act like a bully? If yes, explain ________________________________________________
Has your child been teased? Mildly ______ Some _______ Extreme ________
Sunshine Center offers a family-centered approach to prevention. Programs are most effective when the whole family works together to enhance skills.
Are you willing to participate in a “Parenting Component” for this program?
Yes __________ No ___________ No cost to parent/guardian
(Enhancing parenting skills and reinforcing skills the children are learning this summer)
Best days and times you are available _________________________________________________________
Days and times you are NOT available ______________________________________________________
Parent Name (Print) ______________________________________________________________________________
______ Amount of Deposit you are leaving _______Check # ______ Cash Staff initials _______
_____ Check here if immunization record is attached.
_____ Check here if there is an outside agency responsible for payment (info MUST be complete!)
Name of Agency_____________________________________ Contact Person _______________________
You must have the agency contact us for approval before your child’s space is guaranteed. Please make sure you have this agreement. Parent/guardian is responsible if the agency fails to pay.
STAFF ONLY-**Payment Info:
Staff Only: *** ALLERGY INFO: