JCC Teen Program Registration Form

JCC Teen Program Registration Form
Program ________________________________________________________________________________________________________________
Participant’s Name ______________________________________________Participant’s Cell ________________Date of Birth _____________
Address ______________________________________________ City ___________________ State _______________ Zip __________________
Parent 1 Name ___________________________________________________________________________________________________________
Parent 1 Cell Phone __________________________________________ Parent 1 Home Phone _________________________________________
Parent 1 Email __________________________________________________________________________________________________________
Parent 2 Name ___________________________________________________________________________________________________________
Parent 2 Cell Phone __________________________________________ Parent 2 Home Phone _________________________________________
Parent 2 Email __________________________________________________________________________________________________________
Participant lives with:
o Parent A only
o Parent B only
o Both o Other: ________________________________________________
EMERGENCY CONTACT PROCEDURES In case of an emergency and neither parent can be reached, the follow person can be contacted:
Name __________________________________________________________________________________________________________________
Cell Phone ________________________________________________Alternate Phone _______________________________________________
Relationship to Participant ________________________________________________________________________________________________
Names of persons to whom participant(s) can be released:
_____________________________________
____________________________________
_____________________________________
SPECIAL MEDICAL CONCERNS
o No
o Yes If yes, specify ______________________________________________________________
Allergies
o No
o Yes
If Yes, Need EpiPen?
o No
o Yes Describe Allergies: _______________________________________
Any Medication taken on a regular basis:
o No
o Yes ____________________________________________________________________
Name of Insurance Provider __________________________________ Name of Policy Holder__________________________________________
Group # ________________________________________Member ID______________________________________________________________
PARENT CUSTODY AUTHORIZATION Children will be released to either parent unless we are notified with proper documentation to do otherwise.
We cannot withhold your child from a parent unless this procedure is followed. Attach copies of your documents. The following people have
restricted access to my children. The appropriate legal documentation is attached.
EXPLANATION OF RESTRICTION: Documents attached (please list with expiration dates)
________________________________________________________________________________________________________________________
PHOTOGRAPH CONSENT I give permission to the JCC to use my child(ren)’s name and photographs in brochures, newspapers, broadcasts,
telecasts, social media, and any other form of communication
Signature______________________________________________________________________Date _____________________________________
MEDICAL/TRIP CONSENT I hereby give my child(ren)________________________________________ permission to attend all trips sponsored
by the Lawrence Family Jewish Community Center, JACOBS FAMILY CAMPUS (JCC) and release the JCC and its representatives from all liability
for any mishap which may befall the above named child(ren). In case of sudden injury or illness, I hereby give authority to any hospital or
doctor selected by the JCC to render immediate aid as may be required at the time for my child's health and safety. I understand that medical
expenses are my responsibility. I hereby assume all risks (injury or illness) for my child and family members that may occur during participation
in any activity or use of facilities owned or rented by the JCC. I hereby agree to in no way hold the management of the JCC, its agents or employees
liable for lost or damaged belongings or injury that my child may sustain while involved at the JCC. The undersigned participant or parent/guardian,
in consideration of participation in this program, indicated on this form agrees to indemnify and hold harmless the Lawrence Family Jewish
Community Center, its representatives, its successors, and assigns and releases the same from any and all liability for any injury or illness which
may be suffered by the participant, named herein arising out of, or in any way connected with the program indicated, and assumes the risk for
such injury or illness. I/we assume financial responsibility for my/our child(ren) and agree to meet all financial obligations as due. I have read
and understand the above statements.
Signature______________________________________________________________________Date _____________________________________
PAYMENT METHOD
o Check #_______________
o Visa
o Mastercard
o Discover
o Cash
CC #______________________________________________________________ Expiration Date ________________CVV __________________
Signature ______________________________________________________________________________________________________________