Summer mini-camp registration form upper camps

Registration Form Please register your child to allow us to staff appropriately. Payment must accompany registration. No credits or refunds will be issued. August 9-13 Hours Member Community For more information, Variety Camp 9 am—3 pm call 954-434-0499, X202 Grades K-8 $275/wk $325/wk $55/day $65/day AM Care 7:30 am— 9 am $25/wk $25/wk Please send in a kosher lunch, swimsuit PM Care 3 pm—6 pm $5/day $5/day and towel everyday. Field trips included. $65/wk $65/wk $15/day $15/day Check which camp and the week &/or days your child will attend. Days: August 9-13 ____ or 8/9 ___ 8/10 ___ 8/11 ___ 8/12 ___ 8/13 ___ AM August 9-13 ____ or 8/9 ___ 8/10 ___ 8/11 ___ 8/12 ___ 8/13 ___ PM August 9-13 ____ or 8/9 ___ 8/10 ___ 8/11 ___ 8/12 ___ 8/13 ___ Child 1’s Name: _____________________________________________________________________ Date of Birth _____/_____/_____ Male ____ Female ____ Does Child 1 have an IEP? No____ Yes ____ Child 1’s Grade: _________ Does your child have allergies? No____ Yes ____ If “yes” please indicate the type of allergy: ___________________________________________________________________________________ Child 2’s Name: _____________________________________________________________________ Date of Birth _____/_____/_____ Male ____ Female ____ Does Child 2 have an IEP? No____ Yes ____ Child 2’s Grade: _________ Does your child have allergies? No____ Yes ____ If “yes” please indicate the type of allergy: ___________________________________________________________________________________ Parent 1’s Name: ___________________________________________________________________ Email: ________________________ Work #: __________________ Cell #: _________________ Parent 2’s Name: ___________________________________________________________________ Email: _________________________ Work #: __________________ Cell #: _________________ Emergency Contact Name: ________________________________ Phone: _________________ Emergency Contact Name: ________________________________ Phone: _________________ Payment amount: ______________________ I give permission for my child to participate in the JSummer Mini-Camp program and authorize the David Posnack JCC to have my child treated in the event of an accident or injury if I cannot be reached. I expressly acknowledge that I release the DPJCC, its staff members and affiliates from all liability for any injury, loss or damage connected in any way whatsoever to participate in the J’s activities. I here- by grant permission, without reservation, to the DPJCC and those authorized by the J to take photographic images, videos, recordings, DVDs and CDs of me and/or my child and to use them in original or modified formats in all media (including, but not limited to, newspa- pers, magazines, radio, television, the DPJCC website, YouTube, Facebook or other social media sites, etc.) now or hereafter, with or without my or my child’s name, for the promotion and/or fundraising activities of the David Posnack JCC. ________________________________________________________ ______________________ Signature of parent or guardian Date