ב"ה

Register

Camper Information
Full Name*
First Name Last Name
Hebrew Name
Age*
Birth Date*

Month Day Year
School*
Grade Completing*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Area Code Phone Number
Child's Cell Phone

Area Code Phone Number
Child's E-mail
How many siblings are you planning to enroll?
Name of Sibling 1
First Name Last Name
Age of Sibling 1*
Name of Sibling 1
First Name Last Name
Age of Sibling 1*
Name of Sibling 2
First Name Last Name
Age of Sibling 2*
Father's Information
Father's Name*
First Name Last Name
Father's Religion*
Father's Occupation*
Father's Business Name*

Father's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's E-mail*
Father's cell*

Area Code Phone Number
Father's Facebook*
Mother's Information
Mother's Name*
First Name Last Name
Mother's Religion*
Mother's Occupation*
Mother's Business Name*

Mother's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's E-mail*
Mother's Cell *

Area Code Phone Number
Mother's Facebook*
Confidential
Is the mother of the child Jewish?*

YesNo
Is the father of the child Jewish?*

YesNo
Were there any conversions or adoptions in the family? *

YesNo
If yes, please describe:*
Marital Status of Parents:*

MarriedSeparatedDivorced
If divorced - how long?
Other
What goals do you have for your child attending JKC Camp?*
Please share any other information you feel is important for JKC Camp to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.
Comments
Emergency File
Please list below two emergency contacts
Emergency Contact 1*
First Name Last Name
Relation to Child*
Phone Number*

Area Code Phone Number
Business Phone

Area Code Phone Number
Emergency Contact 2*
First Name Last Name
Relation to Child*
Phone Number*

Area Code Phone Number
Business Phone

Area Code Phone Number
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

YesNo
If yes, please describe them and indicate special precautions or care needed.*
Doctor's Name*
First Name Last Name
Doctor's Phone*

Area Code Phone Number

Doctor's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Permission for Emergency Medical Treatment:*

As the parent(s) or legal guardian I/we authorize any adult acting on behalf of JKC Camp to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, JKC Camp personnel will try, but are not required, to communicate with me prior to such treatment.I hereby give permission for my child to attend all field trips and outings sponsored by JKC Camp.
Registration Information
$2750 for full summer
$1450 one month

Early bird special!
$2500 for full summer
$1300 for 1 month.

To qualify, application must be submitted before Purim (Regular full price from March 14)
My child will be joining JKC CAMP for the full summer*

yes
My child will be joining JKC CAMP for the following session*

June 30 - July 25July 28 - August 22
My child will be joining JKC CAMP for the following weeks*

Week 1Week 2Week 3Week 4Week 5Week 6Week 7Week 8
____________________________________________________________________________________
Extended Hours:
8:00-9:00am
4:00-5:30pm
There are no discounts and no scholarships available for extended hours.
Do you need extended care services before or after standard program hours?*

YesNo
Full Summer

AM & PM $450AM $300PM $300
Month 1

AM & PM $225AM $150PM $150
Month 2

AM & PM $225AM $150PM $150
Week 1

AM & PM $100AM $75PM $75
Week 2

AM & PM $100AM $75PM $75
Week 3

AM & PM $100AM $75PM $75
Week 4

AM & PM $100AM $75PM $75
Week 5

AM & PM $100AM $75PM $75
Week 6

AM & PM $100AM $75PM $75
Week 7

AM & PM $100AM $75PM $75
Week 8

AM & PM $100AM $75PM $75
Pick up/drop-off times*
Contact Info*
____________________________________________________________________________________
Agreement:
Off-Campus Trips*

Click here to review and agree to terms
I grant permission for my child to participate in off-campus trips and activities organized by JKC Camp, including daily trips to:

- 301 Seabreeze Avenue
- Asser Levy Park (both locations are near JKC Camp)

I understand that JKC Camp will arrange for transportation to and from these trips, and I consent to my child being transported by JKC Camp's designated vehicles/drivers. By checking the box below, I acknowledge that I have read and understood the terms of this consent, and I release and hold harmless JKC Camp and its employees from any claims or liabilities arising from my child's participation in these trips and activities.
Photo/Video Release*

Click here to review and agree to terms
By clicking 'Agree', I give permission for JKC Camp staff and volunteers to take and share photos/videos of my child for promotional and social media use.
____________________________________________________________________________________
Commitment*

I understand that by submitting this form I am committing to pay the above outlined camp fees.
Name*
First Name Last Name
Initials*
Date*

Month Day Year
Secure Online Payment
A $300 flat fee is required for registration. This will be counted towards your tuition payment due before the start of camp.*

$300
Custom price amount, this will be subject to approval from the camp director

$
Additional amount I wish to pay today

$

Payment*

Credit Card Other - I will contact JKC to make my payment

Postal / Zip Code

Country

Total

$0.00
To apply for a scholarship, please click here
Full Name
First Name Last Name
Should be Empty:

This page uses TLS encryption to keep your data secure.

Camper Information

Father's Information

Mother's Information

Confidential

Other

Emergency File

Registration Information

Secure Online Payment