Summer Camp 2015 Registration Form

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Summer Camp 2015 Registration Form Complete all 5 pages and return to MJCC, 6560 Poplar Avenue, Memphis TN, 38138. One form per camper.

1 Summer Camp 2015 Registration Form Complete all 5 pages and return to MJCC, 6560 Poplar Avenue, Memphis TN, One form per camper. Additional forms are available at the MJCC Member Services Desk or jccmemphis.org/camp2015 CAMPER INFO New Camper Returning Camper First Name Last Name Middle Initial Birthdate Age Sex T-shirt Size: Child S M L Adult S M L XL Grade Entering Fall 2015 School MJCC Membership ID Non-member Address City State Zip Code MEDICAL/HEALTH INFO IMPORTANT: Along with this registration form, submit a copy of your child s State of TN Immunization Record. Please notify the MJCC if child is exposed to any communicable disease during the three weeks prior to camp attendance. Camper s Insurance Carrier Policy Holder Name Policy # Please enter approximate dates for each health issue, if applicable: Ear Infection Rheumatic Fever Convulsions Diabetes Behavior Hay Fever Ivy Poisoning, etc. Asthma Chicken Pox Chicken Pox Measles German Measles Mumps Insect Sting Allergy Penicillin Allergy Other Drug Allergy Nut Allergy Other Food Allergy Other diseases or details of above Operations or serious injuries with dates Chronic or recurring illness Current medications Any specific activities to be encouraged? Any specific activities to be restricted? 1 TEAR ME OUT FILL ME OUT SEND ME IN ONE FORM PER CAMPER PAGE 1 OF 5

2 ECC CAMP LEVEL 6/1 6/12 #2518 ➌ ➍ 6/15 6/26 6/29 7/10 7/13 7/24 TOTAL #2519 #2520 #2521 ½ Day All Sessions: $2050/$1530m #2517 Pitzel 3 by 6/2 MWF Full Day: $1030/$770m #2527 MWF Full Day: $1030/$770m #2528 #2523 #2524 #2525 #2526 M-F Full Day All Sessions: $2300/$1780m #2522 MWF Full Day: $1030/$770m #2534 MWF Full Day: $1030/$770m #2535 K tonton 4 by 8/15 #2530 #2531 #2532 #2533 M-F Full Day All Sessions: $2300/$1780m #2529 Gadol Kindergarten #2537 #2538 #2539 M-F Full Day All Sessions: $2300/$1780m #2536 #2540 ECC MJCC Members Only Session 1 AM: $115 #2542 Session 1 PM: $115 #2547 Session 2 AM: $115 #2543 Session 2 PM: $115 #2548 Session 3 AM: $115 #2544 Session 3 PM: $115 #2549 All Sessions AM: $420 #2541 All Sessions PM: $420 #2546 Session 4 AM: $115 #2545 Session 4 PM: $115 #2550 TOTAL CAMP FEE Due when application is submitted. $100 per 2-week session. NON-REFUNDABLE DEPOSIT Options for paying Remaining Balance are on form page 5 of 5. REMAINING BALANCE 2 TEAR ME OUT FILL ME OUT SEND ME IN ONE FORM PER CAMPER PAGE 2 OF 5

3 CAMP LEVEL Yofi Grade 1 6 by 8/15 Osher Grades 2-3 Paeel Grades 4-6 Chofshee Grades 7-8 SPORTS Grades 1-6 6/1 6/5 #2551 #2560 #2568 #2576 ➌ ➍ ➎ ➏ ➐ ➑ 6/8 6/12 6/15 6/19 6/22 6/26 6/29 7/3 7/6 7/10 7/13 7/17 7/20 7/24 TOTAL #2553 #2561 #2569 #2577 $ #2554 #2562 #2570 #2578 #2555 #2563 #2571 #2579 #2556 #2564 #2572 #2580 #2557 #2565 #2573 #2581 ALL-STAR SPORTS: $323/$258m per session ALL OTHER SPORTS CAMPS: $365/$300m per session British Soccer #2584 Basketball #2585 All-Star #2586 Dance #2587 Disc Golf #2588 Girl Power #2589 Flag Football #2590 All-Star #2591 Baseball Tennis #2593 #2592 #2558 #2566 #2574 #2582 Brazil Soccer #2594 Cheer/Gym #2595 SPECIALTY ONE- CAMPS: $365/300 per session TWO- CAMPS: $725/$660m per session SABRA: $1065/$1000 Grades 1-6* Science #2601 LEGO #2602 Princess* Grades 1-3 #2603 Chess #2605 Sabra Program* Grades 2-5 #2604 Science #2607 Theatre* Grades 2-6 #2606 Art #2608 Pirate* Grades 1-3 #2609 Grades 9 10 LIT PROGRAM Session 1: $400 #2630 LIT PROGRAM Session 2: $400 #2631 LEGO #2598 AM CARE ONLY #2613 PM CARE ONLY #2622 Circus #2599 Crafts #2600 LIT PROGRAM Campers do not need to sign up for AM/PM Care. It is already included in their fees. #2614 #2623 #2615 #2624 #2616 #2625 #2617 #2626 #2618 #2627 BOTH All Sessions AM: $495/$396m #2612 All Sessions PM: $625/$500m #2621 #2619 #2628 #2559 #2567 #2575 #2583 FitRanx #2596 Basketball #2597 Art #2610 Rock Band #2611 #2620 #2629 TOTAL CAMP FEE Due when application is submitted. $50 per week. NON-REFUNDABLE DEPOSIT Options for paying Remaining Balance are on form page 5 of 5. REMAINING BALANCE 3 TEAR ME OUT FILL ME OUT SEND ME IN ONE FORM PER CAMPER PAGE 3 OF 5

4 PARENT/GUARDIAN INFO Y N First Name Last Name Middle Initial Marital Status Child lives with this parent Home Phone Work Phone Cell Phone Address (ALL CAMP COMMUNICATION HAPPENS VIA UNLESS OTHERWISE REQUESTED) Y N First Name Last Name Middle Initial Marital Status Child lives with this parent Home Phone Work Phone Cell Phone Address (ALL CAMP COMMUNICATION HAPPENS VIA UNLESS OTHERWISE REQUESTED) EMERGENCY CONTACTS (Other than Parent/Guardian) First Name Last Name Relationship to Child Home Phone Work Phone Cell Phone PICKUP AUTHORIZATION I hereby authorize the following individuals to pick up my camper from Day Camp/PM Care. I understand staff has the obligation, if necessary, to ask for photo ID when individuals listed below are picking up the camper. ➌ ➍ First Name Last Name Relationship to Child Birthdate GROUPMATE REQUESTS We will make every effort to accommodate one request per camper, but cannot guarantee groupmate requests. First Name Last Name First Name Last Name ➌ ➍ 4 TEAR ME OUT FILL ME OUT SEND ME IN ONE FORM PER CAMPER PAGE 4 OF 5

5 SUNSCREEN POLICY MJCC camp participants spend a lot of time outdoors. We follow these policies: Parents/Guardians are responsible for applying the first layer of sunscreen prior to morning drop-off. Parents/Guardians are responsible for providing one sealed container per child with enough sunscreen for later day applications. Camp staff are responsible for ensuring thorough follow-up applications after 1 hour in the water, after 2 hours of activity in the sun (due to perspiration), and/or any other time as needed. The MJCC reserves the right to disallow anyone to participate in the camp program, at any time, for failure to comply. Please note that these decisions were made to protect your child. Furthermore, our staff members have been trained on this subject and understand their responsibilities in observing this policy. I understand that I must apply sunscreen for my child. If my child does not have sunscreen on, they will not be able to participate in outdoor camp activities. Signature of Parent/Guardian FINANCIAL AID Memphis Jewish Community Center has limited funds available for the purpose of providing financial assistance on an individual basis. Applications for financial assistance must be completed and returned to the MJCC by March 15, To request an application, please contact Sarah Sehnert at or ssehnert@jccmemphis.org. Camp Policy and Procedures This application is accepted only upon the completion of all necessary forms and a personal interview with the director, if requested. There will be no refund in the event of cancellation after May 11, All camp fees and membership dues must be paid in full by May 11, 2015, unless payment arrangements were made in advance. In consideration of being permitted to participate in MJCC activities and to use the facilities and equipment, I accept all risk to my child s health and any injury or death that may result from such participation, and I hereby release the MJCC, its Board of Directors, officers, employees and representatives from any and all liability for any and all claims and causes for action from loss or damage to my child s property and for any and all illness and injury to my child, including death that may result from or occur during participation in a MJCC activity. I further agree to indemnify and hold the MJCC and its representatives harmless from liability for the injury or death of any person(s) and damage to property that may result from my child s negligent or intentional act of omission while participating in any activity. The MJCC reserves the right to publish photographs of our members and program participants in newspapers, social media, magazines, brochures, newsletters, and promotional videos on our website. If I cannot be reached in the event of an emergency, I agree to assume all expenses for moving and medically treating my child. I also hereby consent to any treatment, surgery, diagnostic procedures, or the administration of anesthesia which may be carried out based on the medical judgement of the attending physician. Signature of Parent/Guardian Camp Payment Non-Refundable Deposit Options There is a required, Non-Refundable Deposit of $50 per week for Traditional, Sports, and Specialty Camps, including the LIT Program. There is a required, Non-Refundable Deposit of $100 per 2-week session for ECC Camps. I have enclosed a check. Please charge my credit card now. I have submitted my payment online. Remaining Balance Options I authorize you to charge my card for my Remaining Balance in full on May 11, 2015.* I will bring a check to the MJCC for my Remaining Balance before May 11, 2015.* I would like to set up a 3-month payment plan for my Remaining Balance. I authorize the MJCC to charge my card in 3 equal payments on March 8, April 8, and May * * If I do not settle my remaining balance by May 11, 2015, I understand my child will not be registered for camp. Signature Credit Card Information Name on Card Card Number Exp. 5 TEAR ME OUT FILL ME OUT SEND ME IN ONE FORM PER CAMPER PAGE 5 OF 5

Town of Dover Recreation Department Day Camp Registration Form

Town of Dover Recreation Department Day Camp Registration Form Name of Camper: Address Age Grade Entering in fall Male/Female Phone # Cell # Date of Birth (Please circle all that apply) Full Day 1. Session