JFLC Summer Camp Registration Form

DATES:

The first week of Summer Camp will begin on June 20-25th. Our last week will be be August 22-26th.

HOURS:

Camp hours are 9 AM - 4 PM. Before and After care is available. If needed, please indicate that on your application below.

RATES:

Camp weekly rates are $225 per week. There are no part time or daily rates offered. The weekly fee which includes:

Special Instructor Fees for the following activities
- Tennis / Karate / Hiking / Fishing / Archery

Sibling discounts are $25 off per additional child

Child 1 ($225)

Child 2 ($200)

Child 3 ($175)

These rates do not include weekly trip fees. Due to high demand, these rates are subject to change.

Camper Information

Camper's Name *

First Name Last Name

Birth Date

Month Day Year

Grade Entering the Fall *

School Attending in the Fall *

Gender

Male Female

Parent/Guardian Information

Name *

First Name Last Name

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe. *

Is the camper prescribed an inhaler? If yes, please explain any instructions. *

Please Select the weeks your camper will attend *

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Jordan Family Learning Center LLC during the selected camp. In exchange for the acceptance of said child’s candidacy by Jordan Family Learning Center LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Jordan Family Learning Center LLC. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Jordan Family Learning Center LLC. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Start Right Now! LLC . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

JFLC Summer Camp Registration

Camper Information

Parent/Guardian Information

AFTER SIGNING, CLICK SUBMIT BUTTON BELOW