Summer Sports Retreat Application

Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Enrollment *

New

Returning

Sibling in program

Sibling in Program

First Name

Last Name

Registration *

4 weeks | $2380

5 weeks | $2975

6 weeks | $3570

7 weeks | $4165

8 weeks | $4760

Dates *

Check the weeks your child will be attending.

Week 1 (June 24-28)

Week 2 (July 1-5)

Week 3 (July 8-12)

Week 4 (July 15-19)

Week 5 (July 22-26)

Week 6 (July 29-Aug 2)

Week 7 (Aug 5-9)

Week 8 (Aug 12-16)

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 #1 *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile *

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Home

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Work

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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

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#2 Home

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#2 Work

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Family Status *

Married

Partnered

Divorced

Separated

Widowed

Single

Parent(s) with Custody *

Both Parents

Mother

Father

Other

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 Phone *

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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 Phone *

(###)

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Authorized #1

First Name

Last Name

Authorized #1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized #1 Primary Phone

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Authorized #1 Secondary Phone

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Authorized #2

First Name

Last Name

Authorized #2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized #2 Primary Phone

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Authorized #2 Secondary Phone

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Authorized #3

First Name

Last Name

Authorized #3 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized #3 Primary Phone

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Authorized #3 Secondary Phone

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Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone

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