Rosen JCC: Early Childhood Camp Application - Summer 2021

ECLC Summer Camp Enrollment Form

Summer 2021
Welcome to the Rosen JCC's Early Childhood Learning Center 2021 Camp Enrollment Form.

Our 2021 Summer Camp Programs are currently at capacity!

If you have any questions, please contact Dr. Phyllis Bochman at Phyllisb@rosenjcc.org or 321-319-4702.

Section 1 - Rosen JCC Membership
Are you a current Rosen JCC member? *

Yes No
Would you be interested in learning more about the benefits of Rosen JCC membership? *

Yes No

Section 2 - Camper Information

Next, help us learn a little more about your camper. This information will help us provide the best possible care for your child.
Camper's Name *

First Name Last Name
Gender *

Male Female
Cutoff Date

Month Day Year
Birthdate *

Month Day Year
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.
Camper T-Shirt Size

Section 5 - Terms and Conditions
Please read and check each item. *
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

Month Day Year
Additional Comments
Should be Empty: