First Name   Middle Initial   Last Name

Male: Female: Date of Birth (mm/dd/yyyy): Grade entering 9/08: - 6 7 8 9 10 11 12 college other

Street Address:

City: State: - select state - New York Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Postal Code:

Home Phone First emergency contact name and # Second emergency contact name and #

School entering 9/08: School District:

Parent's Email:

Parent/Applicant is an employee of:   CSHL NS-LIJ Health System Employed in :   dept/lab.

There are three ways to register for summer camps:
1. Preferred method is to register online and pay via Pay Pal.
2. Register online and mail in your payment.
3. Download and print an application form (or call and we will mail one to you), complete it, and mail with payment.

Your application will not be processed until payment is received. Upon completion of the registration process, you will be mailed a letter of confirmation. Application deadline is May 30th.

We will continue to accept applications as long as there are openings. We require three weeks notice, in writing, for rescheduling camp dates. All cancellation requests must be in writing and signed by parent or guardian. To be eligible for a refund, cancellation letters must be received by the Dolan DNA Learning Center four weeks prior to the session start date – no exceptions. You will receive written confirmation of your cancellation. A $75.00 administrative fee will be deducted from each refund. The DNALC reserves the right to cancel any session due to insufficient enrollment or other unforeseen circumstance.

In order to protect students with peanut allergies, we ask you to please avoid sending lunch or snacks that contain peanuts, peanut oil, or any tree nut.

Parent will provide transportation and lunch/beverage. Students should be dropped off and picked up curbside. A staff person will be in attendance each morning and afternoon to assist students.

I grant permission do not grant permission to the DNALC to use photographs of my child in connection with publicity for the DNALC/Cold Spring Harbor Laboratory. If you agree, a Model Release form will be sent home with your child for your acceptance and signature.

Please contact us at 516-367-5170 if your child has any special needs that we should be aware of.