Camp Baker
2012 Camp Baker Registration Form
Family information: ARE YOU A MEMBER OF THE JCC?: YES NO
WE ARE A RETURNING JCC CAMP BAKER FAMILY
LAST NAME
ADDRESS
CITY
STATE
PARENT 1 NAME
PHONE 1
ZIP
PARENT 2 NAME
PHONE 2
PHONE 1
PHONE 2
PARENT’S MARITAL STATUS: MARRIED SEPARATED DIVORCED WIDOWED OTHER
CAMPER ONE LAST NAME
FIRST NAME
CAMPER TWO LAST NAME
FIRST NAME
CAMPER THREE LAST NAME
FIRST NAME
PARENT/GUARDIAN SIGNATURE (REQUIRED)
DATE
Additional Information HOW DID YOU HEAR ABOUT US - PLEASE ELABORATE:
REFERRAL - WHO MAY WE THANK FOR REFERRING YOU TO CAMP BAKER: Payment Options STEP 1: METHOD OF PAYMENT FOR DEPOSIT Check (made payable to the Charleston JCC) Cash Bill Credit Card Below STEP 2: Early Bird Registration 1 Early Bird Registration 2 Regular Registration STEP 3: METHOD OF PAYMENT Payment in full (enclosed) Check (made payable to the Charleston JCC) Cash Credit Card Registrations received after June 1st and not paid in full will have their payment processed on the Friday prior to the session beginning.
Credit Card Information PARENT’S NAME
BILLING ADDRESS
CITY
PHONE #
STATE
ZIP
VISA MASTERCARD DISCOVER NAME AS IT APPEARS ON CARD
CREDIT CARD #
EXP DATE
SECURITY CODE
Photo/Video Release The Charleston JCC does not have permission to use photographs/video images of my child for publicity purposes, including but not limited to use on the JCC website, CJF website, and in printed materials.
Camper #1 Information
GRADE (AS OF 9/1/12)
CAMPER #1 NAME
BIRTHDATE
AGE (AS OF 9/1/12)
MALE FEMALE
T-SHIRT SIZE: Y-XS Y-S Y-M Y-L A-S A-M A-L A-XL
Transportation
Indicate Specific Sessions Wanted
ROUTE 1: EAST COOPER & NORTH CHARLESTON
1
2
3
4
$75/2week Session (Office Use Only)
ROUTE 2: JAMES ISLAND & WEST ASHLEY
1
2
3
4
Camp Name
Indicate Specific Sessions Wanted
Cost/2week Session (Office Use Only)
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
PRE CAMP
1
POST CAMP
1
2
AM CARE
1
2
3
4
PM CARE
1
2
3
4
CAMPER INSURANCE TOTAL:
$45/camper $
Camper #2 Information
GRADE (AS OF 9/1/12)
CAMPER #2 NAME
BIRTHDATE
AGE (AS OF 9/1/12)
MALE FEMALE
T-SHIRT SIZE: Y-XS Y-S Y-M Y-L A-S A-M A-L A-XL
Transportation
Indicate Specific Sessions Wanted
ROUTE 1: EAST COOPER & NORTH CHARLESTON
1
2
3
4
$75/2week Session (Office Use Only)
ROUTE 2: JAMES ISLAND & WEST ASHLEY
1
2
3
4
Camp Name
Indicate Specific Sessions Wanted
Cost/2week Session (Office Use Only)
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
3
4
3
4
PRE CAMP
1
POST CAMP
1
2
AM CARE
1
2
PM CARE
1
2
CAMPER INSURANCE TOTAL:
$45/camper $
Camper #3 Information
GRADE (AS OF 9/1/12)
CAMPER #3 NAME
BIRTHDATE
AGE (AS OF 9/1/12)
T-SHIRT SIZE: Y-XS Y-S Y-M Y-L A-S A-M A-L A-XL
Transportation
Indicate Specific Sessions Wanted
ROUTE 1: EAST COOPER & NORTH CHARLESTON
1
2
3
4
$75/2week Session (Office Use Only)
ROUTE 2: JAMES ISLAND & WEST ASHLEY
1
2
3
4
Camp Name
Indicate Specific Sessions Wanted
Cost/2week Session (Office Use Only)
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
PRE CAMP
1
POST CAMP
1
2
AM CARE
1
2
3
4
PM CARE
1
2
3
4
CAMPER INSURANCE TOTAL:
$45/camper $
MALE FEMALE