2017 camp registration form

CAMP JCC

SUMMER 2017 REGISTRATION FORM

Please print & return form to Customer Service desk at the Simon Family JCC • 5000 Corporate Woods Drive, Virginia Beach, 23462 • 757-321-2338 CHILD INFORMATION (one child per form)

First Name

Last Name

Nickname

City

Address

-

State

Zip

-

Child’s Cell Phone (if applicable)

Child’s Email (if applicable) Yes, I have a sibling at Camp JCC

Grade (as of 9/5/17)

Age (by 09/30/17)

School Attending in 2017-2018

Doctor’s Name Is Child a JCC Member

Phone Number Yes

No

-

-

Male

Female

Yes

Jewish (Optional)

No

Birth Date Child Adult T-Shirt Size (cannot guarantee after 5/16/17)

How did you hear about us?

Child Resides with

-

Mother

Father

Both

Size

Other

If the parents are divorced or legally separated and one parent has been granted sole custody, control, care and supervision of the child, that parent must provide appropriate court documents.

PARENT/GUARDIAN 1

First Name

Last Name

No Yes Active Military

Relationship

Address

City

-

-

Home Phone

-

State

-

-

Cell Phone

Occupation

Zip

-

Work Phone

Place of Employment

Email

PARENT/GUARDIAN 2

First Name

Last Name

Address

City

Home Phone

Occupation

No Yes Active Military

Relationship

-

-

State

-

-

Cell Phone

Place of Employment

Work Phone

Email

Zip

-

EMERGENCY CONTACT 1

REQUIRED

IN THE EVENT THAT PARENT/GUARDIAN CANNOT BE REACHED (SHOULD NOT BE THE SAME AS PARENT/GUARDIAN LISTED ON PAGE 1).

Last Name

First Name

-

-

Home Phone

Relationship

-

-

-

Cell Phone

-

Work Phone

EMERGENCY CONTACT 2

REQUIRED

IN THE EVENT THAT PARENT/GUARDIAN CANNOT BE REACHED (SHOULD NOT BE THE SAME AS PARENT/GUARDIAN LISTED ON PAGE 1).

Last Name

First Name

-

-

Home Phone

Relationship

-

-

-

Cell Phone

-

Work Phone

PERSONS AUTHORIZED TO PICK UP YOUR CHILD IN ADDITION TO PARENT/GUARDIAN AND EMERGENCY CONTACTS.

Last Name

First Name

Relationship

Last Name

First Name

Relationship

Last Name

First Name

Relationship

MEDICAL INFORMATION The Simon Family JCC strives to provide an all-inclusive summer camp program. Please provide us with information relating to any special physical, emotional, behavioral or developmental needs that your child may have:

Providing this information will assist us in promoting the safety and enjoyment of your child. An intake meeting may be requested to ensure communication of needs and strengths.

Please check this box if you would like to have a special consultation regarding your child’s needs.

Are there any medical conditions and/or birthmarks that we should be aware of?

If so, what are the symptoms and actions to be taken if any (include medications):

Are there any allergies that we should be aware of?

If so, please list

Yes

No

Yes

No

CAMP JCC REGISTRATION FORM

Child’s Name

PRESCHOOL (2 yrs old – rising kindergarten) WEEK 1

WEEK 2

(6/19 – 6/23)

WEEK 4

WEEK 3

(6/26 – 6/30)

PRESCHOOL CAMP

ELEMENTARY (rising 1 – 6 grade)

(7/3 – 7/7)

(7/10 – 7/14)

TEEN (rising 7 – 9 grade)

WEEK 5

(7/17 – 7/21)

CITs (rising 9 – 11 grade)

WEEK 6

WEEK 7

(7/24 – 7/28)

(7/31 – 8/4)

Age Sept. 2017 Sessions

WEEK 8

(8/7 – 8/11)

Cost per Week

Cost with JCC Member Discount

Cost per Week

Cost with JCC Member Discount

Extended Day (T, Th)

$40

$40

$145

$105

Extended Day (M, W, F)

$55

$55

$210

$150

Before Care

$55

$45

Half Day (M-F)

$270

$190

After Care

$60

$50

Full Day

$345

$270

Before & After Care

$100

$90

Sessions Half Day (T, Th)

For 2 year olds only

Half Day (M,W,F)

For 2 & 3 year olds

ELEMENTARY CAMP

TEEN CAMP

Grade Sept. 2017

Cost per Week

Cost with JCC Member Discount

Full Day

$360

$285

Before Care

$55

After Care Before & After Care

Sessions

CITs

Grade Sept. 2017

Cost per Week

Cost with JCC Member Discount

Full Day

$360

$285

$45

Before Care

$55

$45

$60

$50

After Care

$60

$50

$100

$90

Before & After Care

$100

$90

Session Monday - Friday

Cost per week

Cost with JCC Member Discount

8:30am - 3:30pm

$165

$90

Session Monday - Friday

Cost per week

Cost with JCC Member Discount

6:30am - 6:00pm

$360

$285

Grade Sept. 2017

A CIT application must be submitted; then each applicant will have a personal interview with the Camp Directors. CITs must attend 2 consecutive weeks before attending additional weeks.

Sessions

POST CAMP (rising Pre-K – 6 grade)

SESSION 1

(8/14 – 8/18)

SESSION 2

(8/21 – 8/25

DEPOSITS AND PAYMENT OF CAMP FEES A non-refundable deposit of 25% of the total fees is due at the time of registration, with the remaining balance due by June 1, 2017. Registration after June 1, 2017 requires payment in full.

Simon Family JCC membership must be maintained in good standing throughout the camp season in order to receive member rates.

We accept cash, check, VISA, MasterCard and Discover.

SIBLING DISCOUNT If 2 or more children from the same family membership are registered for the same week, families receive a discount of $25 per child per week for every child after the first enrollee.

FINANCIAL ASSISTANCE The JCC strives to ensure no child is denied a camp experience. Scholarships are available. Completed Applications including all requested documentation are due by April17, 2017. Applications received after April 17 will be held and considered after May 15th and only if funding is still available. Applications are available at www.CampJCCvb.org and at the JCC Customer Service Desk.

CANCELLATION & REFUND POLICY All cancellations must be in writing 14 days prior to the start of the week of camp to be cancelled. All deposits are non-refundable. Parents cancelling after the 14-day deadline may be responsible for any remaining balance of the cancelled week.

Unfortunately, we are unable to reduce fees due to absence, illness, family matters, holidays (including July 4), or vacations. All deposits are nonrefundable. The JCC makes every effort to provide campers with a great camping experience and cannot be held responsible for natural disasters that may interfere with the camp experience. Therefore, we do not provide refunds.

FEES DUE AT ENROLLMENT

CAMP FEES

+ Camp Fees

0

= Donation to Scholarship Fund*

FEE TOTAL

+

0

=

Deposit

TOTAL DUE AT ENROLLMENT

Additional Payment

(25% of Camp Fees)

PAYMENT AGREEMENT & CREDIT CARD INFORMATION I have read all payment information and understand said policy. I understand what I am responsible for and that my child will NOT be allowed to start camp weeks/sessions if there is an outstanding balance due for that session. If my child is dropped off without payment made, I will be called to pick up my child from the JCC Summer Camp, immediately. (PLEASE SIGN TO ACKNOWLEDGE STATEMENT REGARDLESS OF PAYMENT METHOD.) Name on Card Card Number

-

Exp. Date

Signature

CVV

-

Date

-

PARTICIPATION AGREEMENT & PHOTO RELEASE I give permission for my child (ages 4 and up) to ride a bus to and from off campus activities. My child has my permission to participate in swimming activities. My camper’s photo, slide, video or quotes may be used by the Simon Family JCC and Camp JCC in marketing materials or on their social media sites (names will be withheld). I give permission for my children to be released to authorized people listed in this application.

Parent/Guardian Signature

Date

ADMINISTRATIVE USE ONLY Received by

Date

-

-

-

-