Alper JCC Summer Camp 2017 by Alper JCC

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Activities Include

Required Attach current school photo of camper here

Dave and Mary Alper Jewish Community Center on The Jay Morton-Levinthal Campus 11155 SW 112 Avenue, Miami, FL 33176 305.271.9000 x270, x271 or x263 Email: jcovas@alperjcc.org www.alperjcc.org

Camper #1

Please write name on back of photo

Camper #2 Please write name on back of photo

JCC Summer Camp 2017 Registration Form

JCC Family Membership is required to register for camp

Member Number: _______________

Camper #1 Last Name: ___________________________First Name: _________________DOB: _____________Gender: __M or __F Race (optional): __White

__American Indian

__Asian

__Black or African American

__Other

Ethnicity (optional): __Hispanic

__ Haitian

__Other

Age by 9/1/2017: ______________ Grade Entering 8/2017: ______________ School: ______________________________________________________ T-shirt size (please circle):

Child:

YXS

YXL

Adult:

MED

X-LG

XXLG (Camp shirts may run small)

Bunkmates (must be reciprocal, same camp unit and dismissal time): 1) _______________________________ 2) __________________________________ Camp Unit (please circle)

K’tanim (2yrs by 8/31/2017) to 2:30 Chaverim/Yeladim (3 & 4yrs) to 2:30 Sabra (1st grade) Tsofim (4th- 5th grades) Habimahettes (2nd grade)

K’tanim (2yrs by 8/31/2017) to 4:00 Chaverim/Yeladim (3 & 4yrs) to 4:00 Jr. Maccabi (1st grade) Rishonim (6th- 9th grades) Habimah (3rd- 8th grades)

Robotics (1st – 5th grades) – Sessions 1A & 2A ONLY Kadima (Kindergarten) Bonim/Halutzim (2nd– 3rd grades) Maccabi (2nd- 9th grades) LIT (9th grade) - Interview Required

*CAMP DATES ARE SUBJECT TO CHANGE (please circle): All 8 Weeks June 12 – August 4 1st Session June 12 - July 7 2nd Session July 10 - August 4 1A June 12 - June 23 2A July 10 - July 21 1B June 26 - July 7 2B July 24 - August 4 Does your child have a documented disability? Yes or No If yes, please describe____________________________________________________________ Does your child need additional accommodations? Yes or No If yes, please describe_________________________________________________________ __ Check here if you are registering for the Special Needs Inclusion Program: In order to begin the camp inclusion intake process please contact Johana Sarmiento at 305.271.9000 x273 or jsarmiento@alperjcc.org before registering. Please check the following if applicable: AM/PM Care (extra fee)

All campers including LIT's being dropped off at the JCC BEFORE 8:45am or picked up AFTER 4:00pm MUST be enrolled in AM or PM care. No camper will be allowed to roam or be unsupervised before or after camp at the JCC. NO EXCEPTIONS!

______AM Care (7:30-9:00am)

_______PM Care (4-6pm)

_________ Both AM and PM Care

Allergies or Medical Issues: _______________________________________________________________________________________________________________ Medications: ____________________________________________________________________________________________________________________________

Camper #2 Last Name: ___________________________First Name: _________________DOB: _____________Gender: __M or __F Race (optional): __White

__American Indian

__Asian

__Black or African American

__Other

Ethnicity (optional): __Hispanic

__ Haitian

__Other

Age by 9/1/2017: ______________ Grade Entering 8/2017: ______________ School: ______________________________________________________ T-shirt size (please circle):

Child:

YXS

YXL

Adult:

MED

X-LG

XXLG (Camp shirts may run small)

Bunkmates (must be reciprocal, same camp unit and dismissal time): 1) _______________________________ 2) __________________________________ Camp Unit (please circle)

K’tanim (2yrs by 8/31/2017) to 2:30 Chaverim/Yeladim (3 & 4yrs) to 2:30 Sabra (1st grade) Tsofim (4th- 5th grades) Habimahettes (2nd grade)

K’tanim (2yrs by 8/31/2017) to 4:00 Chaverim/Yeladim (3 & 4yrs) to 4:00 Jr. Maccabi (1st grade) Rishonim (6th- 9th grades) Habimah (3rd- 8th grades)

Robotics (1st – 5th grades) – Sessions 1A & 2A ONLY Kadima (Kindergarten) Bonim/Halutzim (2nd– 3rd grades) Maccabi (2nd- 9th grades) LIT (9th grade) - Interview Required

______AM Care (7:30-9:00am)

_______PM Care (4-6pm)

_________ Both AM and PM Care

Dave and Mary Alper Jewish Community Center Summer Camp 2017 Payment Worksheet

Membership #__________________

Date______________

Parent's First Name__________________________________________ Last Name__________________________________________________ Child's Name

Camp Fees

AM/PM Care

Deposit DUE NOW ($250 Per Child)

Total Fees

Balance (Total fees - Deposit)

**Yes ______(Initial) I would like to help send another child to camp and donate money towards the JCC Camp Scholarship Fund (Optional)

Please add $___________ to my camp balance

TOTALS

$ $

JCC Membership Form must accompany Camp Registration. The Summer Membership is $199 for returning camp families and is valid from 6/1/2017 - 8/31/2017. Payment Options (Please Choose One) Deposit (REQUIRED) $ _____________ □ Check # ________ □ Credit Card □ Debit Credit Card

(Please see reverse side to pay by AMEX/MC/VISA)

□ I will pay camp fees in Full Now $_____________ □ Check # ________ □ Credit Card □ Debit Credit Card

(Please see reverse side to pay by AMEX/MC/VISA)

□ Please charge my credit card in full for the balance of camp on Monday, May 1, 2017 $ ___________ (Please see reverse side) □ I will pay ______________(# of payments) of $_______________ (Camp must be paid in full by Monday, May 1, 2017) (Please see reverse side for automatic Credit Card Debit or Electronic Transfer from your checking account)

□ I am applying for fee adjustment. It will be my responsibility to have the completed Financial Aide Application including my most recent tax return submitted to the JCC Membership Office no later then Friday, March 17, 2017. FULL DEPOSIT OF $250 PER CHILD AND PAYMENT INFORMATION IS STILL REQUIRED WHEN APPLYING FOR FINANCIAL AIDE. Please read carefully: ° All participants must have a JCC FAMILY MEMBERSHIP. ° All participants must have NO OUTSTANDING BALANCES with the Alper JCC. ° All monthly payments must be made by monthly Credit Card Debits or Electronic Fund Transfer from your checking account. ° All camp balances must be paid in full by Monday, May 1, 2017. ° Any payment that is delinquent may result in your child(ren) being withdrawn or participation being disrupted until the account is made current. ° Any payment that is returned from the bank will be charged with a $25 bank fee. This will be added to your account. ° Deposit is Non-Refundable I have read the above and I promise to pay the Alper JCC Camp Program as per my choice indicated above. The Alper JCC reserves the right to collect late charges and late payment fees. Notice of default is waived. I understand that in the event of default I will be responsible for the cost of collection/attorney fees by the Alper JCC, and that my child will be removed from the program and membership privileges will be suspended until such time as I rectify the situation. Venue for suit will be Miami-Dade County, Florida. Print Name _________________________________________________________________________________________________________________________________________ Signature (REQUIRED) ________________________________________________________________________________________________________________________________

Dave and Mary Alper Jewish Community Center on The Jay Morton-Levinthal Campus 11155 SW 112th Avenue Miami, Florida 33176 Tel. 305.271.9000 Fax 305.595.1902 www.alperjcc.org

JCC Summer Camp Payment Plan Authorization Form

Please select a camp payment plan from the options below and return this form promptly. Questions about your payment? Please call 305.271.9000 x270 or email jcovas@alperjcc.org Please call the accounting office at x228 or email eschwartz@alperjcc.org if there is a change with your credit card or checking account. Name:____________________________________________________________________Membership #:______________________________ Name of Child(ren):___________________________________________________________________________________________________ Billing Address:___________________________________________City, State, Zip:_______________________________________________ Home Phone:_____________________________________Work Phone:_________________________________________________________ Cell Phone:_______________________________________Email:______________________________________________________________

CREDIT CARD (All payment plan charges will be made on the 5th of every month) Deposit Now $____________ Charge my Credit Card in FULL Now $____________ Charge my Credit Card in full for the balance of camp on Monday, May 1, 2017 $____________ I wish to arrange for the Alper JCC to charge my Credit Card ____________ (# of payments) pre-authorized monthly charges of $____________ per month. Starting Date: ____________ Ending Date: ____________(These payments will be charged on the 5th of every month) Charge my:

VISA

MASTERCARD

AMEX

_____ **Check here if your Credit Card is a Debit Card

Account #:___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Exp. Date:__ __/__ __ CVV:____________ Cardholder's Name (as it appears on card):_______________________________________________________________________________ Signature:________________________________________________________________Date:___________________________

DAVE AND MARY ALPER JCC MONTHLY ACH ELECTRONIC DEBIT AUTHORIZATION FORM Please attach a VOIDED check from your account (All debits will be made on the 3rd of every month) I authorize the Dave and Mary Alper Jewish Community Center, Inc. hereinafter named ("Alper JCC") to ACH/electronically Checking Account / Savings Account (select one ) at the depository financial institution named below I agree that ACH transactions I authorize comply with all law. Depository Name:___________________________________________________________________________________________ ABA/Routing #:___ ___ ___ ___ ___ ___ ___ ___ Bank Account #:___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __ Please choose 1 option below: Debit my account in full for the balance of camp on May 3, 2017 $____________ I wish to arrange for the Alper JCC to debit my checking account ____________ (# of payments) pre-authorized monthly debit(s) of $____________ per month. Starting Date: ____________ Ending Date: ____________ I understand that this authorization will remain in full force and effect until I notify the Alper JCC in writing that I wish to revoke this authorization. I understand that the Alper JCC requires 30 days prior notice in order to cancel this authorization. I understand that a sufficient balance and/or credit line must be maintained in my account to fulfill my monthly obligation. I understand that insufficient funds and/or denial of payment to the the Alper JCC will result in a $25 service charge for each case of insufficient funds and/or denial of payment to the the Alper JCC, which will be deducted from my credit card or checking account.

Name(s)/Title(s): __________________________________________________________________________ (please print) Signature: _______________________________________________________________________________ Date: _____________