2017 Summer Day Camp Application (Payment Plan)

2017 Summer Day Camp Application (Payment Plan)
If you have multiple children, please submit one application for each child.
Are you a Member? *
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Please Select a Camp you would like to Enroll in:

(Child’s Age and Grade is as of 9/1/2016)
Camp:
(Please check one) *






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Please select which week(s) the camper will attend
(Please fill out 1 form and 1 medical per camper)
Weeks: *









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If child is not attending 5 days per week please indicate days of week they will attend:
Days:
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Continue to Camper Information:

   

Camper Information:

First Name: *
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Last Name: *
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Birthdate: *
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Gender: *
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Home Address: *
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City: *
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State: *
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Zip: *
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Continue to Parent / Guardian Information:

   

Parent / Guardian Information:

Parent / Guardian 1:
Parent / Guardian's Name: *
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Home Phone: *
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Cell Phone: *
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Email Address: *
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Parent / Guardian 2:
Parent / Guardian's Name: *
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Home Phone: *
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Cell Phone: *
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Email Address: *
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In case of Emergency Contact:
Name of Emergency Contact:
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Phone:
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My child has special needs: *
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My child has a TSS worker: *
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Continue to Trips & Rates:

   

Please check trips your Mitzvah Campers will attend:

(NOTE: Trips are now no additional cost.)
Trips:
(Mitzvah Campers) *




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Continue to Bus Transportation:

   

2017 Day Camp Bus Transportation:

(The Autistic Campers’ Group, July 10-August 4th will take a bus from the Wilkes-Barre JCC at 11:30 am each day and return to the Wilkes-Barre JCC at 4:30 pm, leaving the campsite at 4:00 pm.)

2017 JCC Day Camp Bus Stops (all times subject to change)

Bus 1:
Mt Top Shopping Center
Heights Murray School
Kistler School
State Street School
Chase Corners

Bus 2:
Laflin Boro Bldg
Pittston Area High School
Voitek TV Exeter
Affinity Hair
Wyoming Shopping Ctr
Murray & Durkee (Forty Fort)
Murray & Oak (Forty Fort)
Murray & Slocum (Forty Fort)

Bus 3:
Ridge & Chester
Butler & Tioga
E Dorrance & Meadowland
E Dorrance & Charles
James & Westmoreland
W Dorrance & Mercer

Bus 4:
JCC
Kirby Park near Wilkes Field Hockey
Friedman Center for Jewish Life (3rd Avenue)
Andy’s Photo
Thomas’ Market, Shavertown

Bus 5:
Treasure House, Clarks Summit
Scranton
Treasure House, Chinchilla

Bus:
(Please indicate bus number) *






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Bus Stop:
(See above)
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Continue to Before / After Camp:

   

Before Camp / After Camp:

Fee: $ 25.00 per Week per Session
OR $ 5.00 per Day per Session

AM Care:

(Select days needed)
Week 1:
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Week 2:
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Week 3:
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Week 4:
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Week 5:
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Week 6:
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Week 7:
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Week 8:
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Week 9:
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Week 10
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PM Care:

(Select days needed)
Week 1:
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Week 2:
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Week 3:
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Week 4:
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Week 5:
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Week 6:
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Week 7:
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Week 8:
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Week 9:
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Week 10:
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Camper's Name: *
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Camper's Phone: *
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Camper's Grade: *
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Contact Sara Pisarz at the JCC at 570-824-4646 to arrange Before Care and/or After Care for the season.

Continue to Release of Liability:

   

Release of Liability:

Read Carefully - This Affects Your Legal Rights
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*
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Audio / Video / Web Release Form:

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*
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Transfer & Cancellation Policy:

Missed days of camp are not refunded or transferred. $ 20 fee to transfer weeks — $ 50 fee to cancel camp up to Wednesday before camp begins. ALL CAMP FEES MUST BE PAID IN FULL TO JCA BEFORE CAMPER CAN BEGIN TO PARTICIPATE. Parent is responsible for all fees that have been contracted on application.

Discounts:

There will be a 2% sibling discount & 5% discount for 6 weeks or more for each camper. If camper is registered and paid in full by Thursday, April 16, you will receive a 5% discount on each camper. All fees must be paid in full to JCA before camper can begin to participate. Missed days of camp are not refunded or transferred (E.G. Missed Friday and want to came back next week for a day)

No discounts on Mitzvah trip weeks.
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Payment Plan Deposit Required Now:

*
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Choose Payment Method:
Total 0.00 USD
Phone:
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