Rosen JCC: Early Childhood School, Camp, and Membership Application (School Year 2021-2022)

2021-22 Early Childhood Learning Center Enrollment Form

Please complete this form to begin the Early Childhood Learning Center (ECLC) registration process for the 2021-22 Camp and/or School Year. Every ECLC student must register for the new school year which starts with Camp on Monday, June 7, 2021. If you choose “SCHOOL ONLY,” your child will begin on Monday, August 9, 2021.

Early bird registration for currently enrolled families is $175 and $225 for new families until April 2nd. After April 2nd, the registration fee for current families will be $225 for currently enrolled students and $275 for new students.

You must fill out ONE REGISTRATION PER CHILD. If you have more than one child, please submit this registration and then re-submit a new one for each additional child.

View the 2021-22 ECLC School Calendar here. 2021-22 Tuition and Rates can be viewed here.

Please note that registration is on a space-available basis, and that space is not guaranteed until we receive your registration fee and VPK certificate (if applicable).

Once we receive your registration form, you will automatically be charged the applicable registration fee for 2021-22 school year to your account. If your child is a new student, you will be contacted by the school office.

You will receive an email before April 1st with a link to complete the Parent Packet, which will be due by May 1st. Per DCF regulations, children will not be able to attend school until these documents are received by the JCC, including current immunization and physical forms.

If you are only interested in our ECLC Summer Camp Program, please click here to register.

If you have any questions, contact Dr. Phyllis Bochman at Phyllisb@rosenjcc.org or 321-319-4702.
Rosen JCC: Early Childhood School, Camp, and Membership Application (School Year 2021-2022)
Are you a current member of the Rosen JCC?*

YesNo
Which program will your child attend?*

12-month Program - Summer Program and School (June 7-May 31)10-month Program - School Only (August 9-May 31)
Child's Name*

First NameLast Name
Current Classroom*
If you are registering a new student who is not currently enrolled in the Early Childhood program, please select Not Currently Enrolled. If you are re-registering a student who IS currently enrolled in the Early Childhood program, please select their current classroom.
Gender*

MaleFemale
Cutoff Date

MonthDayYear
Birthdate*

MonthDayYear
Age as of 9/1/21
This is calculated automatically based on the birthdate above.
Allergies/Special Needs*
If none, please enter "None" in the box.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Family Religion(s)*

JewishCatholicMuslimProtestantHinduBuddhistNoneOther
Parent 1 Name*

First NameLast Name
Parent 1 Birthdate*

MonthDayYear
Date
Relation to Child*
Parent 1 Cell Phone*

Area CodePhone Number
Parent 1 E-mail*
Parent 1 Occupation*
Parent 1 Employer
If there are two parents, do they live together?*

Parents live togetherParents live apartOnly 1 parent
Parent 2 Name

First NameLast Name
Parent 2 Birthdate

MonthDayYear
Date
Relation to Child
Parent 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent 2 Cell Phone

Area CodePhone Number
Parent 2 E-mail
Parent 2 Occupation
Parent 2 Employer
What is the relationship between the two parents?

Married/PartnersDivorced/SeparatedWidowed
Program*

Noah's Ark - 8 weeks old by by 9/1/21Toddlers - 12 months by 9/1/21Twos - 2 years by 9/1/21Threes - 3 years by 9/1/21Pre-K/VPK - 4 years by 9/1/21VPK Virtual Flex Program (until December 30, 2021) [Pending State Approval]Kindergarten - 5 years by 9/1/21
Intended Start Date*

MonthDayYear
Program Hours (Noah's Ark)*

5 days (Mon-Fri), 7am-6:00pm3 days (M/W/F), 7am-6:00pm2 days (Tu/Th), 7am-6:00pm
Program Hours (Toddlers & Twos)*

5 days (Mon-Fri), 9am-12:30pm5 days (Mon-Fri), 9am-3pm5 days (Mon-Fri), 7am-6:00pm3 days (M/W/F), 9am-3pm3 days (M/W/F), 7am-6:00pm2 days (Tu/Th), 9am-3pm2 days (Tu/Th), 7am-6:00pm
Program Hours (Threes)*

5 days (Mon-Fri), 9am-3pm5 days (Mon-Fri), 7am-6:00pm3 days (M/W/F), 9am-3pm3 days (M/W/F), 7am-6:00pm2 days (Tu/Th), 9am-3pm2 days (Tu/Th), 7am-6:00pm
Program Hours (Pre-K)*

5 days (Mon-Fri), 9am-3pm5 days (Mon-Fri), 7am-6:00pm5 days (Mon-Fri), 9am-12pm (VPK only)5 days (Mon-Fri), 12pm-3pm (VPK only)
Program Hours (Kindergarten)*

5 days (Mon-Fri), 9am-3pm5 days (Mon-Fri), 7am-6:00pm
Do you want your child to nap?*

YesNo
Do you need extended care from 7-9 a.m.?*

Yes ($125/month)No
Do you need extended care from 3-4 p.m.?*

Yes ($125/month)No
Teacher Appreciation Fund

Families are encouraged to participate in our Teacher Appreciation Fund, which is used to provide holiday gifts, gift cards, meals and events in appreciation of our teachers. By checking this box, I understand I will be charged $100 per child. Payments can be made from either a checking account that is on file, by check, or cash. You will be charged the first month your child attends school, and then two months later ($50 each payment). Participation is optional.
Kindergarten Textbook Fee*
Please read and check each item.*
Registration Fee*

Returning Families - $225New Families - $275
Were you referred by anyone? Please enter their full name.
This question is only applicable for NEW STUDENTS (students who have never been enrolled in the Early Childhood Learning Center before).
Employee Code
If given an Employee Code, enter it here. Otherwise, leave this blank.
By signing below, I agree that I have read and understand the terms of ECLC enrollment, the Membership Agreement and the Waiver, Release and Indemnification Agreement.*
Today's Date

MonthDayYear
Additional Comments
Should be Empty: