PHASE Camp Signup

Welcome to PHASE Program- Peer Health Ambassador Summer Enrichment!

This summer program will run from July 11th to August 18th on Mondays and Thursdays between 4 and 6 pm. This program offers personal development lessons, sexual health education, art, yoga, and plant activities, games, and guest speakers! You can receive job references, community service hours, letters of recommendation, and cool swag!

This event is hosted at the Boys and Girls Club of Bellport and is run by educators from Planned Parenthood Hudson Peconic.

If you have questions contact Aviva Frank, PREP Health Educator, at Aviva.Frank@PPHP.org

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* 1. What is your name?

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* 2. What is your date of birth?

Date / Time

Date

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* 3. Please provide your personal email

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* 4. Please provide a parent or guaridan's email

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* 5. Please provide a phone number for a parent or guardian

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* 6. What is your address?

Address line 1

Address line 2

Town, State, zip code

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* 7. Do you have proof of vaccination?

Yes, I have been vaccinated.

Yes, I have been vaccinated and boosted.

No, I have not been vaccinated.

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* 8. What is your shirt size? (Sizes are unisex adult)

2XL

3XL

Other (please specify)