Personal Information

Camper Age (as of 9/1/19) Gender Grade (as of 9/19)

Member Guest

Date of Birth Address School attending in fall 2019

City State Zip Code Home Phone #

Parent/Guardian Relationship Address (if different from camper)

City State Zip Code Home Phone #

Work Phone # Cell Phone # / Carrier E-mail

Parent/Guardian Relationship Address (if different from camper) Authorized to pickup child at camp Yes No

City State Zip Code Home Phone #

Work Phone # Cell Phone # / Carrier E-mail

Emergency Information

Doctor Phone # Dentist Phone #

Life threatening illness, allergies or special needs: Emergency procedures to follow (all medications must be turned into camp office):

No known illness, allergy or special needs

To help us meet your camper’s needs, please tell us if your child has been diagnosed with anything that requires medication, special

accommodations or therapy: Yes No If yes, please explain ________________________________________________________________

No additional persons may pick up my child. The following additional persons are authorized to pick up my child from the JCA:

Name Relationship Home Phone # Work Phone # Cell Phone #

1.

2.

3.

JCA Office Use OnlyDate and time entered:

2019 SUMMER CAMP APPLICATION

Please check all appropriate boxes. Indicate choices where necessary.

Session(s) (for Gan Yeladim, KinderCamp, Sabra, Habonim and J-Teens)

Shavuot Option (6/11 - 6/21) I (6/10 - 6/21) II (6/24 - 7/5) no camp July 4 III (7/8 - 7/19) IV ( 7/22 - 8/2)

Camp Gan Yeladim Age Groups: Patty Cakes (age 2 by 9/1/19) K’Ton (age 3 by 9/1/19) Tovim (age 4 by 9/1/19)

Days

T/Th Mon/Wed/Fri

Tim

es 9 - 12 9 - 1:30* 9 - 3:30 *for Tovim only

Mon - Fri 9 - 12 9 - 1:30* 9 - 3:30 7:30 - 3:30 9 - 6 7:30 - 6

KinderCamp (entering K by 9/1/19) Times: 9 - 1:30 9 - 3:30 7:30 - 3:30 9 - 6 7:30 - 6

Camp Sabra (entering grades 1 - 2 by 9/1/19) Times: 9 - 3:30 7:30 - 3:30 9 - 6 7:30 - 6

Camp Habonim (entering grades 3 - 6 by 9/1/19) Times: 9 - 3:30 7:30 - 3:30 9 - 6 7:30 - 6

Specialty Choices: Please select your camper’s specialty program per session by indicating the 1st, 2nd and 3rd choice in the space provided before each specialty. ( * indicates additional charge for these specialty selections)

Session I ___

AdventureLanding* ___

Basketball ___

Cooking Around the World ___

Horseback* (Departs at 8 am) ___

Lego Lab ___

Reddi-Arts* ___

Tennis

Session II ___

Chess Club ___

Edge Rock* ___

Fencing ___

Flag Football ___

Ice Skating* ___

Pottery

___

U-Tube Fever*

Session III ___

All Wet Sports* ___

B3 Future Vet* ___

Fashion Design ___

Jacksonville Journey* ___

Mixed Martial Arts ___

Racquet Sports ___

Soccer

Session IV ___

B3: Engineer* ___

Baker’s Dozen ___

Golf* ___

Hip Hop ___

Lacrosse ___

Painting Pizzazz ___

Sailing*

Theatre Camp (entering grades 1 - 9 by 9/1/19) Session(s): Shavuot Option (6/11 - 7/5*) I (6/10 - 7/5*) *no camp on July 4 II (7/8 - 8/2)

Times: 9 - 3:30 7:30 - 3:30 9 - 6 7:30 - 6

J-Teens (entering grades 10 - 12 by 9/1/19)

Adventure Days (entering grades K - 8 by 9/1/19)

Pre Camp (6/3 - 6/7) Post Camp (8/5 - 8/9) Sports Track Art Track

Times: 9 - 3:30 7:30 - 3:30 9 - 6 7:30 - 6

Extended Care If you have registered for 7:30 am or 6 pm care, please indicate your approximate drop-off and pick up times:

______________ am and ______________ pm

I hereby grant permission for my Patty Cake, K’Ton, Tovim, KinderCamp, Adventure Days or Sabra camper to participate in swim instruction at the JCA. I hereby grant permission for my Habonim, Adventure Days or J-Teen camper to participate in field trips or specialties away from the JCA. I give permission to the JCA to authorize any emergency action necessary to ensure the safety of my child. I understand that the JCA is not financially responsible for medical or emergency care given to my child. I permit the free use of our names and/or pictures in broadcasts, newspapers, brochures, Facebook, JCA website or other forms of communication.

Please fully complete and return camp application form to the Registrar’s Office; incomplete forms will be returned with deposit, and spaces will not be guaranteed until forms are returned with complete information. The person signing below accepts financial responsibility for 100% of camp fees. I have enclosed a nonrefundable, nontransferable deposit per session (see Fees and Deposits) and understand that the full balance of payment is due by May 3, 2019.

Signature of parent or guardian

Please check here if you would like an application for financial assistance.Complete applications are due by March 15, 2019 to be considered; 2018 tax return required.

Date and time received: _______________________ Received by: __________________________________________

Entered: _________________________________ Confirmed: _________________________________

Date and Initial Date and Initial

JCA OFFICE USE

ONLY

FEES AND DEPOSITSApplicants must be in good financial standing with the JCA to register for any camp program. All applications must be turned in to the Registrar’s Office.

REQUIRED DEPOSITS PER SESSION, PER CHILD

Adventure Days, Sabra, Habonim, KinderCamp, Gan Yeladim, J-Teens M - F $75

Gan Yeladim T/Th $25

Gan Yeladim M/W/F $50

Theatre M - F $150

Extended Day $25

Deposits are not refundable or transferable to other JCA programs outside of camp. Sabra, Habonim and Theatre offer a 5% discount for campers who register for a minimum of eight weeks with full payment at the time of registration. This discount is applicable only for these camps and offered until February 22. Payments must be made by cash or check only. No discounts on Habonim specialty programs. This discount does not apply to those receiving financial assistance.Balances for all camp programs regardless of session must be paid in full by May 3. The JCA will not guarantee placement if balances are outstanding after that date.Refunds of camp fees for any sessions will be granted, less deposits, only if the JCA is notified in writing of withdrawal prior to May 3. Notification of withdrawal on or after May 3 results in loss of all fees paid.All changes (in writing) regarding registration, including schedules, sessions and specialties, result in a $15 per change fee payable at the time the change is made. On or after May 3, there is no credit issued for changes to schedules with lesser tuitions. Camp fees include lunch for Adventure Days, Sabra, Habonim and Theatre, a camp t-shirt and daily snack.

REGISTRATIONCamps are open to all children regardless of race, religious affiliation or ethnic origin. Membership is not required, but JCA members and Patty Cake age children registered for the 2019-20 Preschool/PreschoolPlus program have priority registration through March 22. Guests are encouraged to submit applications with deposits early to secure a space on the waiting list. In the event space is not available, all monies are refunded.Cabin requests must be reciprocal and written on registration forms. Our cabin groups are designed to meet each camper’s individual needs; however, the JCA reserves the right to discontinue service in the event that a camper’s placement does not serve the best interests of the individual or group.

FINANCIAL AIDAdjusted fees are available on the basis of financial need and the availability of funds. Fee adjustment forms, with required documentation including 2018 tax return, must be received by March 15 to be considered for disbursement by April 1. Late applications are accepted until April 30 for disbursement of any remaining funds. All paperwork must be fully completed. Please indicate on your registration form if you wish to receive a fee adjustment packet. Full deposits are still required upon application. If financial aid is insufficient or unavailable, deposits are refunded. For more information, contact Nancy Green at 730-2100 at ext. 247.

JCA Registrar | ext. 228 or 233 | programregistrar@jcajax.org