PAYMENT INFORMATION FORM Camp Hilbert Registration Form
First Name Please print clearly and complete a separate registration form for each camper.
All campers must submit the All Camps Registration Form and Payment Form along with this registration.
City/State/Zip
Last Name
Address
Phone (Home) (Work)
Membership #
Scholarships
Child’s Name:_________________________________________________ Birthdate:___________________________ Grade (Fall ‘20):_________
r I am not a Weinstein JCC member
Follow these 3 easy steps for registration!
For Camp Hilbert and Specialty Camps only; does not apply to
12-month families.
Select all weeks that after-care will be utilized at $30 per week.
Deadline for scholarship applications is April 17, 2020
Scholarship does not apply to Specialty Camps.
Payment Options
r Week 1 r Week 4 r Week 7 r Week 10
r Week 2 r Week 5 r Week 8 r Week 11
r Week 3 r Week 6 r Week 9
1: Choose your camper’s group 2: Choose your camper’s week s 3: Choose your camper’s transportation
MY CAMPER’S UNIT: (Cost is per week)
❑ Rishonim
❑ Aleph
❑ Habonim
(Rising Kindergarten)
$325M/$390NM
(Rising 1st - 4th)
$335M/$400NM
(Rising 5th - 6th)
$360M/$430NM
❑ Gesher ❑ Post-Camp
(Rising 7th - 8th)
$375M/$450NM (Rising K - 8th)
$325M/$390NM
r Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT)
Pre-authorized debit on the 15th of each month from your checking
account. Your first monthly payment and voided check will be required
to set up this option.
Authorization Agreement for Pre-Arranged Payments (Debits)
I (We) authorize the Weinstein JCC to initiate debit entries to my (our)
checking account maintained at the bank named below, herein after
called Bank.
This authority is to remain in full force and effect until Bank has received
written notification from me (or either of us) to its termination in such
time and in such manner as to afford Bank a reasonable time to act on
it. A customer also has the right to question Bank about any debit entry
by notifying Bank no later than 60 days after Bank sends a statement
to customer containing the entry. Bank will handle all such questions
in accordance with its procedures and the requirements for resolving
errors found in Regulation E issued by the Federal Reserve Board.
# of Months _________ Start Month (must begin by June)
Credit Card MY CAMPER’S WEEKS:
Please complete the appropriate form with credit card number,
expiration date, preferred process date and signature. (Pre-authoriza-
tion from your VISA, American Express or MasterCard monthly.) ❑ All summer: Please sign my child up for all nine weeks of Camp Hilbert
r Visa
r Mastercard
❑ Week 1
r American Express
Bank Name
Signature
Please staple voided check to the top of this page
# of Months _________ Start Date (must begin by June)
❑ Week 5
First Name
❑ Week 3
June 22 - 26
❑ Week 6
July 13 - 17
Last Name
❑ Week 4
June 29 - July 2
July 6 - 10
❑ Week 7
July 20 - 24
❑ Week 8
July 27 - 31
Aug. 3 - 7
❑ Week 9
Signature MY CAMPER’S TRANSPORTATION:
r I wish to contribute to the Scholarship Fund to help children
in need attend our life-enriching camps Bus Stop
Weinstein JCC
Tuckahoe Village Shopping Center
The Shops at Wellesley
Stony Point Shopping Center
Contribution Amount for Scholarship $ After-Care Fees
(For Hilbert/Spec.
Camps only)
Contribution
Amount
for Scholarship $ Camp Hilbert Fees $ Specialty Camp Fees $ Camp Ganim Fees $ COUNSELOR IN TRAINING (CIT)
Voices Together Fees $ (Rising 9th & 10th)
Deposit:
$25 per week / per child – $ ❑ Session One: June 15 - 26
$
Batch # ______________ Date Received _______________ Date Entered _______________
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Pick-up
❑
❑
❑
❑
HILBERT 4-WEEK SESSIONS SPECIAL
❑ Weeks 1-4
June 25 - July 10
❑ Weeks 5-8
July 13 - August 7
❑ Rishonim: $315M/$385NM
❑ Noar/Ruach: $325M/$395NM
❑ Habonim: $355M/425NM
❑ Gesher: $370M/445NM
New camper with special needs?
August 10 - 14
Exp. Date ______________________ Security Code
(For rising 9th and 10th graders,
see CIT registration below.)
(Weeks cannot be mixed and matched and
are a package deal.)
HILBERT POST-CAMP
Credit Card #
Total Balance Due by June 1, 2020
Total Fees Less Deposit
Office Use Only: Member # ______________________
June 15 - 19
❑ Week 2
Preferred Process Date (15th, 22nd, or 30th)
S.S.#
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Parent/Guardian email (required; we communicate via email):________________________________________
r Member r Non-Member
After-Care (5:00 - 6:00PM)
r I am interested in scholarship information
Payment Choice:
r Credit Card
r Check
(Cell)
8:00 a.m.
8:15 a.m.
8:30 a.m.
8:10 a.m.
Please call 545-8658 no later than
May 1 to schedule a mandatory
pre-application meeting.
Drop-off
❑
❑
❑
❑
5:00 p.m.
4:50 p.m.
4:50 p.m.
5:10 p.m.
Cost for each session:
$475M/$575NM
❑ Session Two: June 29 - 10
Fees include centralized bus transportation to
and from Camp Hilbert, t-shirt, daily snack and
beverage (campers provide their own dairy
lunch). Extended morning care is included in your
fees and is from 7:30 a.m. until buses depart for
camp. Extended afternoon care at the Weinstein
JCC is $30 per week and is from the time the bu-
ses arrive back at the Weinstein JCC (approximate-
ly 5-6:00 p.m.) See below for more information.
Please note: after May 1, there is a $35 fee for
each change in registration.
Please note! After-Care . 5-6 PM, Monday Through Friday
In order to provide a quality and appropriately staffed program for our children, there is a small fee for our
after-care service. Registration for after-care is due by June 15 or at time of registration. Cost is $30 per week.
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