JCCY Registration Form
K - 3rd Graders
Please Select JCCY Event
*
2/24/24 - JCCY Winter Pajama Party - K-3rd graders, CHILL with your JCCY friends and enjoy a winter themed pajama party with an ice cream sundae bar and a winter craft!
Child's Name
*
First Name
Last Name
Age
*
Grade in School
*
Date of Birth
*
-
Month
-
Day
Year
Date
Does your child have any medical conditions or allergies that we should be aware of?
*
Any additional information you'd like to share about your child?
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Add A Second Child?
*
Yes
No
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Child's Name
*
First Name
Last Name
Age
*
Grade in School
*
Date of Birth
*
-
Month
-
Day
Year
Date
Does your child have any medical conditions or allergies that we should be aware of?
*
Any additional information you'd like to share about your child?
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Add A Third Child?
*
Yes
No
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Child's Name
*
First Name
Last Name
Age
*
Grade in School
*
Date of Birth
*
-
Month
-
Day
Year
Date
Does your child have any medical conditions or allergies that we should be aware of?
*
Any additional information you'd like to share about your child?
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Drop Off / Pick Up Information
Name of Person Dropping Child(ren) Off
*
First Name
Last Name
Relationship to Child(ren)
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name of Person Picking Child(ren) Up
*
First Name
Last Name
Relationship to Child(ren)
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
Name of Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship to Child(ren)
*
Acknowledgment
Please check the boxes below:
*
I agree to follow the guidelines, rules, and policies of the UJCVP.
I allow my child(ren) to be photographed or be the part of video that will be used for marketing, promotion, and advertisements for the UJCVP.
I release the UJCVP from any and all liability from accident or injury to the child during JCC Youth events.
I give permission for my child(ren) to participate in JCC Youth events.
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Payment Details
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