Kids Day Off Camp Registration JASC

JASC Day Camp Registration Form

Paying by check
Parent/Guardian Name*

First NameLast Name
E-mail*
example@example.com
Best phone number to reach parent/guardian*
Format: (000) 000-0000.
HomeWorkCell/Mobile
TextEmailPhone callOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yes, I am a JASC memberNo, I am not a JASC Member
Name of Student #1

First NameLast Name
Date of birth of Student #1

MonthDayYear
Date
List all food allergies Student #1 has:
Camp selection for Student #1
Member - $40 (code: gamecampm1)Non-Member - $45 (code: gamecampnm1)After camp care (1 pm - 3 pm) - $15 (code: caregc1)Clear Selection
Member - $40 (code: nycampm1)Non-Member - $45 (code: nycampnm1)After camp care (1 pm - 3 pm) - $15 (code: careny1)Clear Selection
Name of Student #2 (if applicable)

First NameLast Name
Date of birth of Student #2 (if applicable)

MonthDayYear
Date
List all food allergies Student #1 has:
Camp selection for Student #2
Member - $40 (code: gamecampm2)Non-Member - $45 (code: gamecampnm2)After camp care (1 pm - 3 pm) - $15 (code: caregc2)Clear Selection
Member - $40 (code: nycampm2)Non-Member - $45 (code: nycampnm2)After camp care (1 pm - 3 pm) - $15 (code: careny2)Clear Selection
Name of Student #3 (if applicable)

First NameLast Name
Date of birth of Student #3 (if applicable)

MonthDayYear
Date
List all food allergies Student #3 has:
Camp selection for Student #3
Member - $40 (code: gamecampm3)Non-Member - $45 (code: gamecampnm3)After camp care (1 pm - 3 pm) - $15 (code: caregc3)Clear Selection
Member - $40 (code: nycampm3)Non-Member - $45 (code: nycampnm3)After camp care (1 pm - 3 pm) - $15 (code: careny3)Clear Selection
If you want to register additional campers beyond the three listed above, please fill out this form completely, submit it, and fill out a second form for your additional campers. Thank you.
Name of Emergency Contact

First NameLast Name
Relationship to camper
Phone Number of Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Additional Pick-up Person

First NameLast Name
Additional Pick-up Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Wagashi Day Off Camp - Nerikiri Tsukuri

Friday, March 17, 2023

10 am - 12:30 pm

Japanese Sweets cooking class for elementary students (ages 6 ~ 12)
Please note that this class will be taught in both Japanese & English

For any questions, please contact: programs@jasc-chicago.org.

Languages spoken:

Rows	English	Japanese	Spanish	Other
Child 1
Child 2
Child 3

Allergy restrictions - Please check all that apply. The following traditional Japanese ingredients will be used (but are not limited to):

Rows	Allergic	Not allergic	Not sure
White Rice
Red & White Beans
Sugar
Food Coloring

Please list any food or other allergies your child/children have:
List allergies and if registering multiple children please indicate the child who has each allergy.
YesNo
Photo Release Consent
I hereby grant and authorize JASC to make use of photos involving the child/children listed above in this registration form. I understand that I can withdraw my consent at any time.I do not allow the use of photos of the child/children listed above in this registration form.
Authorized Representative's Name

First NameLast Name
Authorized Representative's relationship to child being registered
Member - One Child $40 (code daycam1)Member - Two Children $80 (code daycam2)Member - Three Children $120 (code daycam3)Member - Extended care plus camp for one child (code daycam1e) $60Member - Extended care plus camp for two children (code daycam2e) $120Member - Extended care plus camp for three children (code daycam3e) $180Clear Selection
Non-member - One Child $45 (code daycanm1)Non-member - Two Children $90 (code daycanm2)Non-member - Three Children $135 (code daycanm3)Non-member - Extended care plus camp for one child (code daycanm1e) $60Non-member - Extended care plus camp for two children (code daycanm2e) $120Non-member - Extended care plus camp for three children (code daycanm3e) $180Clear Selection
- Your Camp Fee Total
- Checks can be dropped off or mailed to:
  
  JASC
  4427 N. Clark Street
  Chicago, IL 60640
  
  Thank you and we look forward to seeing you at day camp!
- Should be Empty:

JASC Day Camp Registration Form

Photo Release Consent