Age 2 thru Pre K Registra on Packet

Camp Informa on 2019 JCC Camp Simchah Age 2 thru Pre K Registra on Packet Welcome to summer camp at the JCC! We are so excited to show you and your family why J Camp is Life! JCC Membership required PRIOR to Camp Registra on If your family is not currently a J Member, you must join as a Camp Friend (a JCC membership only for the me your child is in camp) before this registra on packet will be accepted. To become a J member for no more than $88 a month, please contact our Membership department. If joining as a Camp Friend, a Camp Friend Registra on Form must be completed and the en re Camp Friend fee MUST accompany this registra on. Camp Friend Fees are: $525 per family for 6 9 weeks of camp $280 per family for 2 5 weeks of camp View the benefits of membership at www.jccdallas.org/join and contact our Membership department at 214 239 7138 with any ques ons. Registra on Process To register your child(ren) for camp: Please complete one packet per child The packet must be completed in its en rety and submi ed to the JCC Front Desk. Receipt of these forms by the JCC does not guarantee a space in Camp Simchah. If we are unable to accommodate your camper in the session(s) of your choice, a Camp Director will reach out to you directly to a empt to make alterna ve arrangements. If we cannot make alterna ve arrangements, your camper will not be registered for camp and camp fees will not apply. Camp registra on forms will be accepted based on the following schedule: Priority Registra on for J Members opens at 12:30pm on Sunday, January 20, 2019. Families may join the JCC as J Members on January 20, 2019 to receive the benefit of priority registra on. Camp Friends may also submit this packet beginning at 12:30pm on Sunday, January 20, 2019; however, your forms will be held for processing un l Sunday, January 27, 2019 when registra on opens to the community. Completed forms will be processed in the order they are received. In person registra ons receive date/ me stamps, and emailed, faxed, or mailed forms will be stamped as if they were turned in at the END of day they were received. Forms submi ed prior to January 20th will NOT be accepted. Refund and Change Policies Please be sure to read the camp refund and change policies on the Waiver and Release form inside this packet. Ques ons? If you have any specific ques ons or concerns about Camp Simchah, please contact the Camp Directors: Cynthia Casper, Camp Co Director, ccasper@jccdallas.org or 214 239 7118 Dave Stanton, Camp Co Director, dstanton@jccdallas.org or 214 239 7162 If you have ques ons about the camp registra on process or your specific situa on, please contact Anna Miller Goodman at agoodman@jccdallas.org or 214 239 7125 before turning in your registra on packet. Camp Simchah Informa on, Page I

Parent s Checklist 2019 JCC Camp Simchah We are looking forward to your child joining us at Camp Simchah this summer! Please complete the following steps to register for camp. Step 1: For each child, please complete this registra on packet in its en rety and turn it in to the JCC Front Desk. The following forms must be completed for your child(ren) to a end Camp Simchah. Please complete all necessary forms and turn in to the JCC no later than June 1, 2019 (or ASAP if a er this date). Forms can be found online at www.jccdallas.org/campforms. If you have any specific ques ons or concerns about Camp Simchah or the forms required, you may reach out to the Camp Directors: Cynthia Casper, ccasper@jccdallas.org or 214 239 7118 Dave Stanton, dstanton@jccdallas.org or 214 239 7162 REQUIRED FORMS FOR CAMP SIMCHAH: Camp Friend Registra on Applica on if your family is not a J Member Camper Informa on Form* Waiver and Release* Registra on Form* Camp Simchah Family Profile (Online submission at www.jccdallas.org/campforms) Health Form (Download at www.jccdallas.org/campforms. Must be completed and signed by physician and include copy of child s immuniza on record) Camp Simchah Ge ng to Know You Form (Online submission at www.jccdallas.org/campforms) *located inside this packet FORMS THAT MAY BE REQUIRED FOR CAMP SIMCHAH: Medica on Release Form if camp staff will be administering any medica ons to your child (Online submission at www.jccdallas.org/campforms) Carpool Form if any children outside of your household will be carpooling with your family (Online submission at www.jccdallas.org/campforms) Camp Simchah Informa on, Page II

Camper Informa on Form 2019 JCC Camp Simchah Camper Informa on: Full Name: _ Gender: [ ] Male or [ ] Female Birthdate: / / Age (as of 9/1/19) : School: Home Phone: Home Address: City: Zip: Child Resides With: [ ] Parent 1 and/or [ ] Parent 2 Non Custodial Parent Address (if Applicable): Address: City: Zip: Parent 1 Informa on: Name: Primary Phone: Secondary Phone: Email: Parent 2 Informa on: Name: Primary Phone: Secondary Phone: Email: Medical Informa on: Insurance Carrier: Policy Holder: Policy Number: Physician Name: Physician Phone Number: [ ]Yes or [ ]No : Does the child have any Allergies? If yes, please provide details: [ ]Yes or [ ]No : Does the child take any medica ons? (Please note that Medica on Release Form MUST be completed for any medica on to be administered by camp staff) If yes, please provide details: [ ]Yes or [ ]No : Does the child have any addi onal medical condi on(s) that camp staff should be aware of? If yes, please provide details: Friend Requests: You may request to have your camper placed with at least 1 of the friends listed below 1. 2. Emergency Authoriza on: When no parent can be reached, the following may act on my behalf and my child may be released to (individuals listed below may have access to health informa on about my child): [ ] Emergency Authoriza on Granted to the following individual(s) or [ ] No Emergency Authoriza on Granted Name: Rela on to Child: Primary Phone: _ Secondary Phone: _ Name: Rela on to Child: Primary Phone: _ Secondary Phone: _ To the best of my knowledge, the informa on contained above is true, complete, and accurate. I understand that if any of the informa on above should change, a new Camper Informa on Form should be submi ed to the JCC of Dallas as soon as possible. Signature of Parent : Date: / _ / _ Camp Simchah Registra on Packet, Page 1 of 5

Waiver and Release 2019 JCC Camp Simchah Camper s Full Name: Age (as of 9/1/19): _ REFUND, TRANSFER, AND CHANGE POLICIES 1) Camp Deposits MUST accompany this applica on. Deposits are NOT REFUNDABLE for any reason. 2) Camp Deposits ARE FORFEITED if camper is dropping out or reducing the total me for a camp item (week, session, bus, AM and/or PM care, etc). 3) Transfers and changes are based on availability. A er April 1, 2019 there will be a $50 fee per transfer or change. 4) Complete payment for all sessions is due on or before April 28, 2019. 5) A er May 1, 2019, no refunds will be granted. 6) A er camp has begun, an addi onal 3 week session is $100 more than the 6 or 9 week fee. PARTICIPANT WAIVER AND RELEASE OF LIABILITIES With the realiza on that publicity of programs helps ensure the success of the programs, I hereby grant the Jewish Community Center of Dallas (JCC) full permission to use my/our full name, personal success story, photographs, films, and video of me/my family for the purpose of publicizing the Center. This permission includes but is not limited to iden fica on of my child by name in printed materials, reports, grants, website, Facebook, and other social media. The JCC of Dallas reserves the right to reconsider your child s enrollment if per nent informa on regarding medical, psychological, educa onal, or other relevant evalua on or medical care has not been adequately shared with the camp administra on. If we are unable to accommodate your child s level of func on or if their behavior limits their ability to par cipate in or benefit from our camp program, we reserve the right to reconsider your child s a endance. I give my permission for my child/children to par cipate in all ac vi es of the Jewish Community Center of Dallas, including swimming and field trips (if applicable). I understand that on field trips my child/children will be transported by bus or private automobile (required to par cipate in any camp programming). In the event of an emergency which affects the health of the camper I, undersigned, do hereby authorize officials of the JEWISH COMMUNITY CENTER OF DALLAS to contact directly the persons named on the a ached Camper Informa on Form and if neither parent nor guardian can be contacted, I authorize the physician named on the a ached Camper Informa on Form to render such treatment as may be deemed necessary in an emergency, for the health of the child. I hereby give the personnel of the Jewish Community Center of Dallas permission to make arrangements for emergency medical a en on, to transport the student to an accredited facility for diagnosis and treatment and to authorize emergency administra on of medica on as necessary. I request and authorize physicians, den sts, and staff of the accredited medical facility to perform any diagnos c procedures, treatment procedures, x ray treatments and administra on of anesthe cs as may be necessary in the diagnosis and treatment of minor camper. I understand that I have not been given a guarantee as to the results of examina on or treatment. I agree to pay for the services rendered and expenses incurred pursuant to this authoriza on. Further, I will not hold the Jewish Community Center of Dallas or their Officers, Directors, Administrators, Teachers, Personnel or Employees financially responsible for the emergency care and/or transporta on for said child. The authority granted herein will expire one year from acknowledged date. This is to cer fy that I, as parent/guardian with legal responsibility for the above named Par cipant on behalf of the par cipant do consent and agree to his/her waiver and release as provided above of all the Releases, and, for myself, my spouse or co guardian, heirs, assigns, and next of kin, waive, release and agree to indemnify and hold harmless the Releases from any and all liability, other than gross negligence as defined by Texas law, associated with my minor child s involvement or par cipa on in these programs, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permi ed by law. In considera on of being allowed to par cipate in any way in any program, related events and ac vi es at the JCC or sponsored by the JCC ( programs ) I on my own behalf and on behalf of any minor children for whom I am responsible appreciate and agree that: 1) The risk of injury from the ac vi es involved in programs offered by the JCC may be significant, including the poten al for permanent injury or even more serious consequences, and while par cular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist, and; 2) On my own behalf and on behalf of any minor children for whom I have responsibility, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE JCC, other than gross negligence as defined by Texas law, and those affiliated with the JCC described in Paragraph 4 or others, and assume full responsibility for my and my minor children s par cipa on. If anyone in my family violates any rule or policy of the JCC or otherwise causes a problem that in the sole discre on of the JCC CEO endangers the health, safety or welfare of anyone, the CEO may suspend my family s privilege to be on the JCC campus and par cipate in the JCC s programs, and; 3) I willingly agree to comply with the stated and customary terms and condi ons for par cipa on. If I observe any unusual significant hazard during my presence or par cipa on, I will remove myself and my minor children from par cipa on and bring such to the a en on of the nearest official immediately. 4) I, for myself and on behalf of my minor children, heirs, assigns, personal representa ves and next of kin, HEREBY WAIVE, RE LEASE, INDEMNIFY, AND HOLD HARMLESS THE JCC, their officers, officials, agents and/or employees, other par cipants, sponsoring agencies, sponsors, and, if applicable, owners and lessors (referred to as Releases ) FOR ALL CLAIMS other than gross negligence as defined in Texas law in connec on with any conduct regarding any program at the JCC or any ac vity sponsored by the JCC WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permi ed by law. I HAVE READ THIS WAIVER AND RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Signature of Parent : Date: / _ / _ Camp Simchah Registra on Packet, Page 2 of 5

2019 JCC Camp Simchah Registra on Page 1 of 3 Please complete a separate applica on for each camper. Place a check in the box next to each camp for which you would like to register. Once you have chosen your child s camp schedule, total the camp fees and deposit due on page 3. Note: Campers must be either J Members OR pay the addi onal Camp Friend fee. Camper s Full Name: _ Age (as of 9/1/19): _ Camper s Membership Number: T Shirt Size (Please Select One): [ ] 2T [ ] 3T [ ] 4T [ ] Youth XS 4 5 Session Dates Session 1, Tue, Jun 11 Fri, Jun 28 No camp on Mon, Jun 10 Session 2, Mon, Jul 1 Fri, Jul 19 No camp on Thu, July 4 Session 3, Mon, Jul 22 Fri, Aug 9 Pricing Deadlines Early, On or Before March 1 Regular, March 2 May 1 Late, A er May 1 See the NEXT PAGE for FULL DAY (7:30am 6:00pm) registra on and addi onal programming details! Camp Simchah (Mornings ONLY) 8:45am 12:45pm Do not complete this sec on if registering for Full Day. See next page. Age Group (select one) 2 s (age 2 as of 5/31/19) 3 s (age 3 as of 9/1/19) 4 s (age 4 as of 9/1/19) Monday Friday One Session (3 Weeks) Early (through March 1) $1,026 Regular (March 2 May 1) $1,131 Late (A er May 1) $1,206 Non Refundable deposit $75 Choose one camp session below: Early (through March 1) $1,704 Regular (March 2 May 1) $1,866 Late (A er May 1) $2,004 Non Refundable deposit $150 Early (through March 1) $2,295 Regular (March 2 May 1) $2,520 Late (A er May 1) $2,682 Non Refundable deposit $225 Monday, Wednesday, and Friday 2 s or 3 s ONLY Early (through March 1) $1,308 Regular (March 2 May 1) $1,506 Late (A er May 1) $1,692 Non Refundable deposit $150 Early (through March 1) $1,800 Regular (March 2 May 1) $1,971 Late (A er May 1) $2,205 Non Refundable deposit $225 Camp Simchah Registra on Packet, Page 3 of 5

2019 JCC Camp Simchah Registra on Page 2 of 3 Please complete a separate applica on for each camper. Place a check in the box next to each camp for which you would like to register. Once you have chosen your child s camp schedule, total the camp fees and deposit due on page 3. Note: Campers must be either J Members OR pay the addi onal Camp Friend fee. Camper s Full Name: Age (as of 9/1/19): _ Camper s Membership Number: T Shirt Size (Please Select One): [ ] 2T [ ] 3T [ ] 4T [ ] Youth XS 4 5 Session Dates Session 1, Tue, Jun 11 Fri, Jun 28 No camp on Mon, Jun 10 Session 2, Mon, Jul 1 Fri, Jul 19 No camp on Thu, Jul 4 Session 3, Mon, Jul 22 Fri, Aug 9 Pricing Deadlines Early, On or Before March 1 Regular, March 2 May 1 Late, A er May 1 Camp Simchah FULL DAY: 7:30am 6:00pm Age Group (select one) 2 s (age 2 as of 5/31/19) 3 s (age 3 as of 9/1/19) 4 s (age 4 as of 9/1/19) Monday Friday One Session (3 Weeks) Early (through March 1) $1,698 Regular (March 2 May 1) $1,833 Late (A er May 1) $1,926 Non Refundable deposit $150 Early (through March 1) $2,712 Regular (March 2 May 1) $2,910 Late (A er May 1) $3,078 Non Refundable deposit $300 Early (through March 1) $3,735 Regular (March 2 May 1) $3,987 Late (A er May 1) $4,212 Non Refundable deposit $450 Choose one camp session below: Monday, Wednesday, and Friday 2 s or 3 s ONLY Early (through March 1) $2,094 Regular (March 2 May 1) $2,328 Late (A er May 1) $2,550 Non Refundable deposit $300 Early (through March 1) $2,889 Regular (March 2 May 1) $3,114 Late (A er May 1) $3,411 Non Refundable deposit $450 Addi onal Camp Experiences! Camp Mommy & Me: 9:30am 11:30am, Tuesday and Thursday for ages 12 24 Months Introduce the joy of Camp Simchah to your li lest camper! Parent and child will explore the Camp Simchah experience together, making new friends and learning lifelong skills in a safe and nurturing environment. Enrichment Programs: Available a er Camp Simchah most days, mes will vary depending on ac vity Explore some Camp Simchah favorites such as Tammy Time, Dancing with Suzi, swim lessons at the Lenny Krayzelburg Swim Academy, Gymnas cs, and more! See jccdallas.org/simchah for more informa on and schedules! Camp Simchah Registra on Packet, Page 4 of 5

2019 JCC Camp Simchah Registra on Page 3 of 3 Camper s Full Name: Age (as of 9/1/19): _ Camper s Membership Number: J Members Camp Friends Total Camp Fees from Page 1 or 2 $_ Camp Deposit Due $ Remaining Balance (Due by Apr 28) $ (Total Camp Fees less Deposit) Camp Fees From Page 1 or 2 $ + Camp Friend Fee* $ *fee must be paid in full at registra on Total Camp Fees Due $ Camp Deposit Due $_ Total to be Paid Today: $_ (Minimum due is the Camp Deposit) Camp Friend Fee $_ Remaining Balance (Due by Apr 28) $_ (Total Camp Fees less Camp Friend Fee and Deposit) Total to be Paid Today $_ (Minimum due is Camp Friend Fee & Camp Deposit) Pay in full today Pay deposits today and remaining balance on April 28, 2019 Pay deposits today and equal monthly payments with balance paid by April 28, 2019 Please check preferred date of payment: 7 th 15 th 21 st 28 th I authorize the Jewish Community Center of Dallas to charge my credit card below per the above payment plan: Credit Card Number (VISA or MasterCard only) Expira on Date Signature Date For JCC Use Only: Amount Received: $ Camp Paid by: [ ] Credit Card [ ] Check (enclosed) or [ ] Cash Camp Simchah Registra on Packet, Page 5 of 5