Camp Magazines 2017 Camp Magazine | Page 25

Please print clearly and complete a separate registration form for each family . Camper Information

1 . Last Name ________________________ First Name ________________________ Birthdate __________ Sex ____ Grade ( Fall ‘ 17 ) ___________ Does child receive support services ( OT , PT , Speech , Education , etc .)?* ����Yes ��No Child resides with :_________________________________ 2 . Last Name ________________________ First Name ________________________ Birthdate __________ Sex ____ Grade ( Fall ‘ 17 ) ___________ Does child receive support services ( OT , PT , Speech , Education , etc .)?* ���Yes

��No Child resides with :_________________________________ 3 . Last Name ________________________ First Name ________________________ Birthdate __________ Sex ____ Grade ( Fall ‘ 17 ) ___________

Does child receive support services ( OT , PT , Speech , Education , etc .)?* ���Yes ��No Child resides with :_________________________________ * If checked “ yes ,” you will be contacted regarding your child ’ s specific needs to determine eligibility and to develop support strategies to ensure his or her success at camp . Our goal is to be inclusive , proactive and supportive .

Family Information Member ��� Non-Member � Parent / Guardian 1 ____________________________________________

Parent / Guardian 2 ____________________________________________

Address ___________________________________________________ City / State / Zip ______________________________________________ Home Phone ______________________________________________ Work Phone ______________________ Cell ______________________

Address ____________________________________________________ City / State / Zip _______________________________________________ Home Phone _______________________________________________ Work Phone ______________________ Cell ______________________ Email ____________________________________________________ Email _____________________________________________________ Email addresses will be used to send camp information and photos of camp activities . Addresses will not be released outside of the Weinstein JCC .

Emergency Contact ( other than parents )

Name ______________________________________ Relationship to Child ________________ Phone ________________ Cell / Bus ________________ Name ______________________________________ Relationship to Child ________________ Phone ________________ Cell / Bus ________________ Child will not be released to anyone other than the above without written consent of parent or guardian . Physician ________________________________________________

Phone _______________________________________________________

Payment Policy

PLEASE READ CAREFULLY BEFORE SIGNING . BALANCE MUST BE PAID IN FULL NO LATER THAN JUNE 2 , 2017 , UNLESS A PAYMENT PLAN HAS BEEN CONFIRMED WITH THE WEINSTEIN JCC EXECUTIVE STAFF . FEES MAY BE CHARGED ON MASTERCARD , VISA , AMERICAN EXPRESS OR BY ELECTRONIC FUNDS TRANSFER ( EFT ). THERE WILL BE A $ 35 FEE FOR EACH CHANGE OF REGISTRATION AFTER MAY 1 . Confirmation of applications will be made only to camp registrants whose accounts reflect no balance due for other activity fees .

For Members Only : Weinstein JCC membership must be maintained current throughout the camp season in order to receive member rates . Refund Policy : Once the camping season begins on June 19 , withdrawals from camp will not be refunded .

I understand the Weinstein JCC ’ s policy on camp registration , and I agree to be responsible for payment of all fees due to the Weinstein JCC .

I understand failure to make payments as required will result in termination of service and collection action will be taken . In the event that collection action is taken , I understand I will be responsible for any and all attorney and court costs incurred by the Weinstein JCC .

I hereby grant permission for my child to be included in pictures connected with the summer camp program that may be used in marketing materials or on the official Weinstein JCC Summer Camps Photo Gallery . To withdraw my child from any Weinstein JCC Camp program , I understand that I must submit my request in writing to the appropriate Camp Director . I understand that should I withdraw my child from any Weinstein JCC Camp program after June 19 , I will be responsible for payment in full for all enrolled sessions .

Date ___________________________________________________

Date ____________________________________________________

Mail your Registration Forms to the address below or drop off at Weinstein JCC Central Services / Control Desks Weinstein JCC • 5403 Monument Avenue • Richmond , VA • 23226 • Fax ( 804 ) 285-3139

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