Registration Form - Boulder JCC

SUMMER CAMP 2013
3800 Kalmia Ave, Boulder CO 80301 • preschool@boulderjcc.org
303-448-9939 • fax 303-448-9938
Summer Camp at the JCC preschool is an enriching and playful experience for children ages 18 months - 5
years old (entering kindergarten). Campers will explore nature, gardening, friendships, art, science and music.
During each session there will be a special in-house fieldtrip which will further enhance their camp experience. Our
summer teachers are skilled and creative early childhood educators who will facilitate a fun and stimulating
experience for your child.
To register your child please fill out the form below and return it with a $75 dollar non-refundable
registration fee made payable to Boulder JCC, which will be applied to your first camp payment. We offer a variety
of schedules in two week blocks to accommodate your unique summer schedule. Preschool Camp has a half day
option from 9am to 1pm or a full day option from 9am to 3:30pm, with an early drop-in option from 8:00-9:00am
for an extra $5/day. Camp Inchworm (18 months – 2.5 years) has a short morning option from 9-11:30am or a
longer morning option 9-1, M/W/F, T/Th or M-F.
Child’s name Age Birth date
Street Address
City
ZIP
Home Phone
Email (primary)
Parent 1 Name
Cell/Work Phone
Parent 2 Name
Cell/ Work Phone
Persons to contact in case of an emergency (if parents cannot be reached):
1. Phone
2. Phone
3. Phone
Names of person, other than parents, authorized to take above-named child from the facility.
Pictured driver’s license identification required for pickup.
Name Phone Number Relationship to Child
1.
2.
3.
Summer Camp 2013

Physician to be called in case of emergency:
Phone Number:
Medical Insurance Insurance ID Number Medical Insurance Number
Does your child have any physical or medical limitations? Yes
If yes please explain on a separate piece of paper.
No
Diagnosed
Allergy
Date
discovered
Reaction
Steps teachers should
take
Severity (1 -
10: 10 being
most severe)
It is imperative for us to know what medications your child takes at home and what medications might be taken at school.
All medication to be administered at school must be approved by director and be accompanied by the appropriate
paperwork.
Medication
Reason / Condition
Please indicate any other information that may be helpful to insure the best camp experience
for your child:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Summer Camp 2013

Preschool Camp Sessions Schedule
2½ to 5 years old (entering Kindergarten)
Please check the session(s) you would like to attend and the times. Sessions cannot be brokenup
without director’s approval. Changes also require director’s approval. One change per
family please. Additional camp sessions can be added at any time.
Session 1- June 3-14
Payment due May 3rd
Mon/Wed/Fri (9-1___ 9-3:30____)
Tues/Thurs (9-1___ 9-3:30___)
Mon-Fri (9-1___ 9-3:30___)
Cost $_________________
Session 2- June 17–28
Payment due May 3rd
Mon/Wed/Fri (9-1___ 9-3:30___)
Tues/Thurs (9-1___ 9-3:30___)
Mon-Fri (9-1___ 9-3:30___)
Cost $_________________
Session 3- July 1–12 (no camp July 4 th )
Payment due June 3rd
Mon/Wed/Fri (9-1___ 9-3:30___)
Tues/Thurs (9-1___ 9-3:30___)
Mon-Fri (9-1___ 9-3:30___)
Cost $_________________
Session 4- July 15-26
Payment due June 3rd
Mon/Wed/Fri (9-1___ 9-3:30___)
Tues/Thurs (9-1___ 9-3:30___)
Mon-Fri (9-1___ 9-3:30___)
Cost $_________________
BONUS! Mini-Session July 29–Aug 2
Payment due June 3rd
(Cost is ½ the cost of 2 week session)
Mon/Wed/Fri (9-1___ 9-3:30____)
Tues/Thurs (9-1___ 9-3:30___)
Mon-Fri (9-1___ 9-3:30___)
Cost $_________________
Cost per 2 week session Half Day 9am-1pm:
M/W/F $269.00
T/Th $181.00
M-F $430
Cost per 2 week session Full Day 9am-3:30pm:
M/W/F $341.00
T/Th $221.00
M-F $551.00
Summer Camp 2013

Camp Inchworm Sessions Schedule
18 months to 2.5 years old
Please check the session(s) you would like to attend and the times. Sessions cannot be brokenup
without director’s approval. Changes require Director’s approval.
One change per family please.
Session 1- June 3-14
Payment due May 3rd
Mon/Wed/Fri (9-11:30___ 9-1____)
Tues/Thurs (9-11:30___ 9-1___)
Mon-Fri (9-11:30___ 9-1___)
Cost $_________________
Session 2- June 17–28
Payment due May 3rd
Mon/Wed/Fri (9-11:30___ 9-1____)
Tues/Thurs (9-11:30___ 9-1___)
Mon-Fri (9-11:30___ 9-1___)
Cost $_________________
BONUS! Mini-Session July 29–Aug 2
Payment due June 3rd
(Cost is ½ the cost of 2 week session)
Mon/Wed/Fri (9-11:30___ 9-1____)
Tues/Thurs (9-11:30___ 9-1___)
Mon-Fri (9-11:30___ 9-1___)
Cost $_________________
Session 3- July 1–12 (no camp July 4 th )
Payment due June 3rd
Mon/Wed/Fri (9-11:30___ 9-1____)
Tues/Thurs (9-11:30___ 9-1___)
Mon-Fri (9-11:30___ 9-1___)
Cost $_________________
Session 4- July 15-26
Payment due June 3rd
Mon/Wed/Fri (9-11:30___ 9-1____)
Tues/Thurs (9-11:30___ 9-1___)
Mon-Fri (9-11:30___ 9-1___)
Cost $_________________
Cost per 2 week session 9am-11:30am:
M/W/F $225.00
T/Th $150.00
M-F $350.00
Cost per 2 week session 9am-1pm:
M/W/F $360.00
T/Th $240.00
M-F $560.00
Summer Camp 2013

Please initial to indicate if you would prefer automatic withdrawal when due. ___________
(May 3 rd for sessions 1 and 2; June 3 rd for session 3 and 4 and the mini session) OR initial if you
would prefer to pay by check or manually through Jackrabbit. _______
In the event payment has not been made by the 3 rd of the month, the Boulder JCC Preschool reserves
the right to charge your credit card on the 10 th of the month.
Please provide your credit card information below: (We do not take American Express or Discover)
Credit Card #____________________________________________________
Exp. Date ____________________
I understand that it is my responsibility to notify the director of any intent to withdraw my child from summer
camp. I fully understand and am willing to comply with the policies outlined above. I understand that I am
individually responsible for this account. I am aware of the tuition rates and agree to pay based on my selections
above.
Parent Signature ___________________________________________________Date ________________
Parental Consent and Waiver Form
I understand that there are inherent risks in the variety of activities in which my child will participate during the
BJCC Preschool Summer Camp. By signing this waiver, I state that my child is in proper physical, mental, and
emotional condition to participate in all of the activities including field trips. I waive my right to any and all claims
that I may have against the Boulder JCC, their staff and representatives for any injuries or accidents my child
may suffer as a result of his/her participation there in. I understand that in the event of an emergency and I
cannot be reached, permission is hereby granted to the JCC personnel to secure medical treatment for my child. I
give my permission for any emergency physician to treat the person named above. I accept responsibility for all
medical expenses incurred
Boulder JCC Preschool staff reserves the right to photograph and/or video tape participants in the Boulder JCC
summer program. All photos and/or video tapes will remain the property of the Boulder JCC and may be used for
publicity and promotional purposes.
If you do not wish to have your child photographed or video taped, please let the office know and initial ______.
Please sign this registration form and submit payment to:
Boulder Jewish Community Center Preschool
3800 Kalmia Ave Boulder, CO 80301
If you have any questions, please contact the office at 303-448-9939.
If you cancel before May 3rd, 50% of your tuition will be refunded. No refunds will be given for
cancellations after May 3rd.
Summer Camp 2013

Health and Medical Information
I. Please check one
I am attaching copies of my child's immunization and health forms to the Boulder JCC Preschool
The JCC Preschool has current (within 6 months for toddler and within one year preschoolers)
copies of my child’s immunization and health records.
I hereby request exemption from the Immunization requirements for preschool entry because all
or some immunizations are contrary to my beliefs. I understand that in case of an outbreak of
any one of these diseases, my child may be temporarily excluded from attending for his/her
protection.
II. Please check one
The JCC Preschool has my signed medical policies and procedures form.
I am attaching a signed medical policies and procedure form (see attached form).
Parent’s/Guardian’s Signature________________________________
Date:______
(Please print your name here): _______________________________________________________
By signing, you are agreeing to the above.
If waiver is not signed, participant will not be registered and form will be returned.
Summer Camp 2013

Medication Policies and Permission Slips
2013-2014 School Year
Please read the following carefully and fill out and return the form below with your emergency and health examination forms. We
must have all three forms before we can allow your child to stay at camp or school.
1) Please let us know if your child is on medication of any kind. If your child needs medication during the day you and your
pediatrition must fill out a medication administration form which you can get from the office. All medication must be in original
containers, labeled and will be kept in a lock box in the office. No medication of any kind can be kept in your child’s backpack,
including diaper rash cream. We will keep unexpired medication for one week after disenrollment or school closure. We will be glad
to work with you to accommodate any special needs your child may have.
2) If your child has a chronic condition such as asthma or allergies which requires medication to be kept on site, you and your
pediatrician must fill out a health care plan as well as a medical administration form. This can be found in the office.
3) It is your responsibility to apply sunscreen to your child before preschool or camp. Teachers will be reapplying sunscreen
throughout the day as needed using labeled sunscreen provided by you. Please sign approval form below.
4) We can use diaper rash cream when needed, with parent permission. In order to apply over-the-counter cream to your child, you
must inform their teacher and supply it in its original labeled container. We do not routinely apply cream of any kind. We must have a
doctor’s approval written in a medical administration form to apply any type of prescription or over the counter cream to skin which is
cracked or has open sores.
5) Several of our teachers have been trained in medical administration procedures and will be the ones giving any medication
necessary. We are working closely with a physician’s assistant consultant. All medical information will be kept confidential between
staff. the physician’s assistant and the director.
I give permission for the staff of the Boulder JCC Preschool to apply the sunscreen I have provided to my
child________________________________________________.
Child’s Name
I give permission for the staff of the Boulder JCC Preschool to apply the diaper rash cream I have provided to my
child_________________________________________.
Child’s Name
I give permission to delegated staff to administer medication and share medical information concerning my
child________________________with the physician’s assistant, other staff and the director of the Boulder
JCC preschool. (If you do not give permission, we will not be allowed to administer medication of any kind to your child).
Child’s Name
Print Name______________________________________________________________
Signature________________________________________________________________
Summer Camp 2013