2011 JCC DAY CAMP APPLICATION


Please send one application per child to: JCC, 2 Millstone Campus Drive, St. Louis, MO 63146 Fax #: 314-442-3432


Complete Registration includes: * Application * Deposit * Physician’s Statement * Camp Waiver & Release * Medical Consent/Behavior Policy


REGISTRATION INFORMATION: Other forms are required in addition to this applicaion. When application is received with deposit and payment plan, a place will be held for your child. However, registration is not complete until we receive the Physician’s Statement from September 2009 or later. Protocol Med Consent/Behavior Policy and Camp Waiver and Release which can be found at www.jccstl.com. (If you do not have a current Physician’s Statement at the time of registration, this must be mailed by May 1st or sooner).


JCC Membership # _______________________________________ o Non-Member


Camper’s First Name ___________________________________________________________________ Camper’s Last Name ___________________________________________________________________ o Male o Female Address ___________________________________________________________________________________________________________ City ____________________________________________________________________State _____________Zip ______________________ Home Phone ________________________________________________________________________________________ Camper’s Birth Date _________________________________________________________________________________ Grade in Fall 2011 _______________________________________________ Religious Affiliation __________________________________________________________________________________________________ Does your child have special needs? o Yes o No If yes, please contact inclusion coordinator to discuss Does your child have food or other allergies? o Yes o No If yes, please describe ________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________


Parent #1 Full Name ______________________________________ Home Phone ________________ Cell Phone __________________ Parent #1 e-mail address (Please Print Clearly) __________________________________________________________ Parent #1 Address (if different from child) ______________________________________________________________________________ Parent #2 Full Name ______________________________________ Home Phone ________________ Cell Phone __________________ Parent #2 e-mail address (Please Print Clearly) __________________________________________________________ Parent #2 Address (if different from child) ______________________________________________________________________________


The following people are authorized to pick my child up from the JCC: Name: ______________________________________________________________ Phone: ________________________________________ Name: ______________________________________________________________ Phone: ________________________________________ Name: ______________________________________________________________ Phone: ________________________________________


Camper’s Primary Physician/Medical Group & Phone # __________________________________________________________________ Insurance Company _______________________________________ Insurance ID# _____________________________________________ Name of Insured __________________________________________ In the event that you can’t be reached in an emergency, who should be contacted? 1. _______________________________________________________ Phone ____________________ Cell Phone ____________________ 2. _______________________________________________________ Phone ____________________ Cell Phone ____________________


RELEASE OF INFORMATION Camper’s photo and quotes may be used for publicity purposes. o Yes


o No


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