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BBOED Pre-K 3
Day Care
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Summer Registration
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Programs
BBOED Pre-K 3
Day Care
Preschool
School Vacations
Summer at the J
Swim
About
Who We Are
Facilities & Security
Hours & Closures
Rental Space
Enroll
Admissions
Summer Registration
LWECC Summer Application
Child's Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Enrollment
*
New
Returning
Sibling in school
Sibling in School
First Name
Last Name
Registration
*
Session 1 (6/24-7/19) | $1775
Session 2 (7/22-8/16) | $1775
APPLICATION AGREEMENTS
Financial Agreement
*
I agree to pay the non-refundable registration fee of $200 at the time of registration and the non-refundable summer membership fee of $99 and the program fee selected above by May 24, 2024. As explained in the JCC policy handbook, I understand that I will be charged if I am late to pick up my child. (After 4:30pm: $30/day for Wrap Around Care and After 6:00pm: $5/minute until your child is picked up)
I agree
Policy Confirmation
*
I confirm I have read, understood, and accepted the terms and policies outlined in the JCC policy handbook.
I confirm
Photo & Video Permission
*
I allow photographs and video of my child to be used for future publicity including (but not limited to) our website, our social media channels, program brochures and printed materials.
I do not allow photographs and video of my child to be used for any purpose.
PARENT/GUARDIAN INFORMATION
Please Note: Parent/Guardian #1 is the responsible party for this agreement.
Parent/Guardian #1
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mobile
*
(###)
###
####
Home
(###)
###
####
Work
(###)
###
####
Email
*
Parent/Guardian #2
First Name
Last Name
#2 Address
If different from Parent/Guardian #1
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
#2 Mobile
(###)
###
####
#2 Home
(###)
###
####
#2 Work
(###)
###
####
#2 Email
Family Status
*
Married
Partnered
Divorced
Separated
Widowed
Single
Parent(s) with Custody
*
Both Parents
Mother
Father
Other
Other Custody
If Other was selected above, please include relationship.
Language Spoken at Home
*
EMERGENCY CONTACTS
Please provide 2 emergency contacts other than the parents.
Emergency Contact #1
*
First Name
Last Name
Emergency Contact #1 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact #1 Email
*
Emergency Contact #1 Phone
*
(###)
###
####
Emergency Contact #2
*
First Name
Last Name
Emergency Contact #2 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact #2 Email
*
Emergency Contact #2 Phone
*
(###)
###
####
CHILDREN'S AUTHORIZATION
Persons authorized to assume responsibility for the child if the parent is not available. Only list people that may pick up child.
Authorized #1
First Name
Last Name
Authorized #1 Relationship
Authorized #1 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Authorized #1 Primary Phone
(###)
###
####
Authorized #1 Secondary Phone
(###)
###
####
Authorized #2
First Name
Last Name
Authorized #2 Relationship
Authorized #2 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Authorized #2 Primary Phone
(###)
###
####
Authorized #2 Secondary Phone
(###)
###
####
Authorized #3
First Name
Last Name
Authorized #3 Relationship
Authorized #3 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Authorized #3 Primary Phone
(###)
###
####
Authorized #3 Secondary Phone
(###)
###
####
Unauthorized Persons
Please specify if there is anyone your child should NOT be released to.
Description
Please include a description of the individual(s) your child should not be released to. If you would like to send a photo instead, you can email it to sophie@jccbayonne.org. If a non-custodial parent is not included among the people authorized by the custodial parent to pick up the child, please email a copy of appropriate documents (Court Order) for the child's record to sophie@jccbayonne.org.
INSURANCE INFORMATION
Employer's Information
Employer's Name
Employer's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer's Phone
(###)
###
####
Hospitalization
Insurance Company
Policy Number
Other Pertinent Information
Major Medical
Major Medical Insurance Company
Major Medical Policy Number
Major Medical Other Pertinent Information
