BITS 'N PIECES TUTORIAL SUMMER CAMP 2024 - Registration Form - July 1-August 9, 2024

Sep 19, 2026

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BITS 'N Pieces Tutorial Summer Camp 2024 registration materials for elementary students entering 1st–5th grade at Church Street Elementary School, running July 1 through August 9, 2024 (8:30am–5:00pm). Includes registration requirements, drop-off instructions to the White Plains Youth Bureau, tuition and scholarship amounts, and optional extended day details. Provides student, parent/guardian, emergency contact, medical history, permission/authorization, dismissal arrangements, and parental trip permission and release forms.

LanguageEnglish

CategoryForms

FormatPDF

Pages10

Reading Time4 min

AccessFree to download

Registration Requirements

Student Information

Parents/Guardians Information

Emergency Contact Information

Medical History

Hospital Release/Permission Slip

Arrangements for Dismissal

Parental Trip Permission and Release Form

# BITS 'NPIECES 2024SUMMER ENRICHMENTCAMP Bits'h Pieces isa sixweek tutorial Campthatofferselementary aged children the opportunity to stayon trackwith their studies.The program provides a sare,enjoyableand educational environmentemphasizingreading,writing and critical thinking. Church Street Elementary School Students entering 1st-5th grade July 1-August 9,2024 8:30am -5:00pm Full Fee:$1,072.00 Scholarship:$645.00 Extended day from(5:00-5:30 pm)an additional $33.00/per week ## Registration Requirements 1)Copy of student's physical form AND 2)Copy of immunization form(both must be current within the yearat the time of registration) 3)Copy of Federal 1040 Tax Form 2023(if you are applying for scholarship) 4)Check/Money Order made out to the City of White Plains or Completed Credit CardAuthorization form. Completed registration forms will be accepted by Drop Box Onlylocated in the front entrance of the Youth Bureau: The White Plains Youth Bureau11 Amherst PlaceMonday-Friday 10-6 pm(914)422-1378www.whiteplainsyouthbureau.ora YOUTH BUREAUOFFICE OF THE MAYOR 11 AMHERST PLACE-WHITE PLAINS,NEW YORK 10601(914)422-1378-FAX(914)422-6489www.WhitePlainsYouthBureau.org FRANK WILLIAMS,JR.,Ph.D.EXECUTIVE DIRECTOR THOMAS M.ROACH MAYOR ELIZABETH ALMONTE,MBADEPUTY DIRECTOR ## BITS 'N PIECES TUTORIAL SUMMER CAMP 2024JULY 15T-AUGUST 9TH,2024 | | STUDENT INFORMATION | | | --- | --- | --- | | Child's Name:
Date of Birth___/___/__ | | | | Home Address
Apt.
________Home phone( ).
Zip:____ | | | | Ethnicity/Race___
Age:_________Gender:____T-Shit Size:□ Small □ Medium □ Large □Adult Small | | | | □ Church Street □George Washington □ Mamaroneck □Post Road □Ridgeway | | | | | Grade as of September 2024(please circle one):1t 2nd 3rd | 4th 5h | | | PARENTS/GUARDIANS INFORMATION | | --- | --- | | Parent/Guardian: | Parent/Guardian: | | Cell Number: | CellNumber: | | Work Number: | Work Number: | | E-mail Address:_ | E-mail Address: | ## EMERGENCY CONTACT INFORMATION | | (Person other than parent/guardian required for emergency contact) | | | --- | --- | --- | | Name_ | Phone: | Relationship to child | | Name | Phone: | Relationship to child | | Name | Phone: | Relationship to child | | | OFFICE USE ONLY | | Medical Form___Immunization Form___ Method of Payment_______Last 4 digits Fee Paid Extended Day(5:00 TO 5:30)_____ MEDICAL HISTORY | | (Parent is required to complete th | is section) | | | --- | --- | --- | --- | | Child's Name_ | Date of Birth | | Sex_ | | Name of Parent/Guardian_ | | Phone\#__ | | | Address_____ | | | | | Is child's health generally good?____ | _
____If not,describe according to chart: | | | | Is child subject to: | Allergies: | Food Allergies: | History of Diseases: | | --- | --- | --- | --- | | □Sinus Trouble | □ Poison Ivy | □ Peanuts | □ Chicken Pox | | □ Ear Infections | 口Insect Bites | □ Other Tree Nuts | □ Measles | | □ Convulsions | □ Penicillin | □Other | □ German Measles | | □Sleep Walking | □ Other Drugs | | □ Rheumatic Fever | | OFainting Spells | 口Hay Fever | | | | □Asthma | □ Influenza Type B | | | | | □ Hepatitis B | | | Does your child require an EpiPen,asthma inhaler and/or Benadryl?□Yes □No Note:lf child is required to take any type of medication during camp hours,a separate MEDICAL AUTHORIZATION FORMmust be completed by the PARENT AND PHYSICIAN and filed with Camp Director on the first day of camp. Please list current medications List operations or serious injuries with dates_ List chronic or recurring illnesses Please describe restrictions on your child's participation in activities or necessary modifications Is your child designated throug

FAQs

What documents are required to complete registration (and when must they be current)?

Registration requires a copy of the student’s physical form and a copy of the immunization form, both current within the year at the time of registration. Scholarship applicants must also submit a copy of the Federal 1040 Tax Form for 2023.

How can completed registration forms be submitted?

Completed registration forms are accepted by Drop Box only. The drop box is located at the front entrance of the Youth Bureau at 11 Amherst Place, Monday–Friday 10–6 pm.

What medical and permission information must be provided for camp?

The forms collect medical history (including allergies, diseases, and whether an EpiPen/inhaler/Benadryl is needed), medication and restrictions details, and an emergency hospital release/permission slip. Dismissal and emergency contact information must also be provided.

Sep 19, 2026

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