Summer Camp Registration Form 2021
Email address *
Child's First and Last Name *
Age *
Gender *
Class Entering
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. *
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.
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.
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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