Kids Day Off Camp Registration JASC

JASC New Year's Day Camp Registration Form
New Year's Camp will be on Monday, January 19, 2026 from 9 AM to 3 PM JASC.

This year's camp will feature Japanese New Year’s traditions of 書初め (Kakizome –calligraphy) and 初生け (Hatsuike – flower arranging/ikebana) activities.
Parent/Guardian Name*

First NameLast Name
E-mail*
example@example.com
Best phone number to reach parent/guardian*
This phone is my

HomeWorkCell/Mobile
What is your preferred form of contact - select all that apply:

TextEmailPhone callOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a JASC member?

Yes, I am a JASC memberNo, I am not a JASC Member

Name of Student #2 (if applicable)

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

MonthDayYear
Date
List all food allergies Student #2 has (type N/A):*
If you want to register additional campers beyond the two 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.
Additional Pick-up Person

First NameLast Name
Additional Pick-up Person Phone Number
Please enter a valid phone number.
If someone other than the parent or guardian or emergency contacts listed here is picking your child up, you MUST LIST THE INDIVIDUAL with FULL NAME and with PHONE NUMBER. The individual who picks up your child(ren), MUST SHOW identification (driver's license, state ID, passport).
Photo Release Consent
I hereby authorize Japanese American Service Committee ("JASC") and its representatives to use, print, publish, or display a picture and/or use my name for public relations or other purposes to benefit the JASC and its program. I have read and understand this consent form.

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
Relationship

Camp Fees Total
Members - Please select the camp options you would like to register for:

Member - One Child $80 (code daycam1)Member - Two Children $150 (code daycam2)Clear selection or Plan to pay by check (put class selection in memo area below)
Non-Members - Please select the camp options you would like to register for:

Non-member - One Child $90 (code daycanm1)Non-member - Two Children $170 (code daycanm2)Clear selection or Plan to pay by check (put class selection in memo area below)
Camp Fee Sum Total
If paying by check, please select the camp options you would like to register for:
Your Camp Fee Total for online payment

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USDJASC Day Camps
Please complete your registration by clicking on one of the payment buttons below.

If you pay by a credit card or debit card, please click the submit button below after you enter your card information.

if you pay using a PayPal account, your form will automatically be submitted after you input your payment information.

If you will pay by check sent to the JASC office, please send your check to JASC, 5700 N. Lincoln Ave., Chicago, IL 60659 or drop it off at our office.

Thank you and we look forward to seeing you at day camp!

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

JASC New Year's Day Camp Registration Form