Summer Address:
1010 Niles Pond Rd., Honesdale, PA 18431
(570) 253-3850
Winter Address:
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60 Greenway South, Forest Hills, NY 11375
(718) 261-2267
Irv Bader, Director
SENECA MINI CAMP : SUMMER OF 2017
Name of Camper (Last) ____________________________________ (First) _______________________________ Male___ Female__
Date Of Birth (Month)_________ (Day) _____ (Year) ________ Years at Seneca _________Present Grade (as of Sept. 2016) ____________
Camper cellphone______________________________________ Camper E-mail _______________________________________________
Home Address______________________________________________City______________________________State______Zip_________
Home Telephone______________________________________ E-mail ______________________________________________________
School Presently Attending__________________________________________________Principal_________________________________
Name Of Parents (Father) _________________________________________ (Mother)___________________________________________
Firm Name______________________________________________Business Phone________________________________________
Business Address___________________________________________ City_________________________ State ______Zip____________
Cell Phone #'s (Father) _________________________________________ (Mother) _____________________________________________
Pager #'s (Father / Mother)_____________________________________ Summer Telephone (If different from above)___________________
Summer Address (If different from above) __________________________________________________________________________
I hereby apply for the enrollment of my ___son ___daughter for the 2017 season at Camp Seneca Lake. I agree to pay the sum of $___________ which includes:
round trip transportation from New York City, laundry, insurance, arts & crafts, and educational materials. I understand that Camp Seneca Lake is not responsible for the
camper's personal property.
** In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment,
X-ray for, and to order injection, anesthesia, or surgery for my child as named above.
Sign Here
Parent Signature _____________________________________ Date_________________
SENECA MINI TRIAL CAMP
Sunday, July 23rd til Wednesday July 26th, 2017
Fee: $400
Please note: The $400 tuition cost can be fully applied to summer 2018 if registered by October 15th, 2017
Special Requests:_______________________________________________________________________
_________________________________________________________________________________
This application together with a check for $400 should be mailed to:
Camp Seneca Lake, 60 Greenway South, Forest Hills, NY 11375