Summer Camp Registration Form 2021

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Email *

Child's First and Last Name *

Age *

Gender *

Birthday (MM/DD/YYYY) *

Home Address, City, State, Zip *

Home Phone Number

Mother's Name, Cell Phone Number, Email Address *

Father's Name, Cell Phone Number, Email Address *

Sessions and Fee Schedule: Your child's spot will be confirmed once we receive the registration fee. Select all which apply. *

Non-Refundable Registration Fee: $120

Half Day Camp: $200/week

Full Day Camp: $275/week

Required

Help A Child! There are children whose parents cannot afford the cost of day camp. Your contribution will give them the fun they so rightly deserve.

Give a child a week of fun.: $300

Give a child a summer of fun.: $1375

1st Emergency Contact: Full Name, Full Address, Relationship to Child, Phone Number *

2nd Emergency Contact: Full Name, Full Address, Relationship to Child, Phone Number *

Child Personal Medical Information: Name of Insurance Provider and Policy Number *

Child Personal Medical Information: Doctor's Name, Phone Number, Address *

Child Personal Medical Information: Allergies or Medical Conditions *

Child Personal Medical Information: Check all that apply.

My child requires an Epipen.

My child needs to take medication during camp hours.

Waiver

Parental Consent: I hereby permit my child to participate in all activities of JCP Summer Camp. I have read and agree to the terms and conditions in the waiver above. I understand that my child may be dismissed during a camp day due to illness, at the discretion of the camp, and I agree to abide by the director's decision. The parent who signs this registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fees. Please write your full name below. *

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