2020 Free Summer Reading & Enrichment Program at the Historic Salem Courthouse
This Program is for Those Children Entering Grades K - 3 (2020-2021 School Year)
Program Dates: July 6 - August 6
Times: Monday through Thursday 9AM - 11AM
Program Address: Historic Salem Courthouse, 58 East Broadway Salem NY 12865
Contact us at (518) 854-7053 or hscpa@salemcourthouse.org
Application Due Date: June 26, 2020

All NYS Covid-19 Guidelines will be followed – Daily parent/child check-in required
Masks will be provided for children unless they prefer to bring their own.
Space is limited and a lottery system will determine acceptance.

If you choose to participate, we expect your child to attend all scheduled sessions,
EXCEPT when they show signs of fever or sickness.

***Parents will receive a call by July 1 to notify you of your child's acceptance and inform you of his/her scheduled days***
Email address *
Student First Name *
Student Last Name *
Address *
Grade in 2020/2021 School Year *
Child's Age *
Child's Date of Birth *
MM
/
DD
/
YYYY
Home Phone Number *
Mother's Name *
Mother's Cell Number *
Father's Name *
Father's Cell Number *
Emergency Contact Name and Number *
Names of People Who May Pick Up Child *
Does Your Child Have Any Allergies? *
If You Answered "Yes" Above, What Allergies Does Your Child Have?
How Will Your Child Get To/From the Salem Courthouse? (Check All That Apply) *
Required
Select the Days Your Child will Attend *
Required
I agree to bring my child to the check in station at the Courthouse each of their scheduled mornings for the NYS check-in procedures. Please indicate your acceptance by selecting 'Yes' below. *
My Child Can Participate in the 2020 Summer Program *
My Child Can Be in a Picture Taken with Others *
First Aid/Medical Care Can Be Administered if Needed *
I Give My Child Permission to Attend this Program *
Required
Parent Printed Name *
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