Camp Magazines 2019 Camps Magazine | Page 29

ALL CAMPS REGISTRATION FORM Please print clearly and complete a separate registration form for each family. Camper Information 1. Last Name________________________ First Name________________________ Birthdate__________ Sex____ Grade (Fall ‘19) ___________ Does child receive support services (OT, PT, Speech, Educational, etc.)?* r Yes r No Child resides with:________________________________ 2. Last Name________________________ First Name________________________ Birthdate__________ Sex____ Grade (Fall ‘19) ___________ Does child receive support services (OT, PT, Speech, Educational, etc.)?* r Yes r No Child resides with:________________________________ 3. Last Name________________________ First Name________________________ Birthdate__________ Sex____ Grade (Fall ‘19) ___________ Does child receive support services (OT, PT, Speech, Educational, etc.)?* r Yes r 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 r Member r Non-Member Parent/Guardian 1___________________________________________ Parent/Guardian 2____________________________________________ Address___________________________________________________ Address____________________________________________________ City/State/Zip______________________________________________ City/State/Zip_______________________________________________ Home Phone ______________________________________________ Home Phone _______________________________________________ Work Phone ______________________ Cell_____________________ 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 1, 2019, 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 APRIL 30. 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 17, 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 17, I will be responsible for payment in full for all enrolled sessions. X______________________________________________________ Signature of Parent or Legal Guardian X______________________________________________________ Signature of Person Responsible for Payment (if different) Date___________________________________________________ Date____________________________________________________ Scan, email, fax or mail your registration form to: Joey Wood at [email protected] • Fax [phone] • Phone: [phone] Or drop-off at Central Services/Control Desks at 5403 Monument Avenue, Richmond, VA 23226 29