JVSF Registration

Summer Fun Program Registration

Use this form to register for Jimmy Vejar Summer Fun in Rye Brook 2025 and pay by credit card. One form per participant; those with multiple participants will need to fill out multiple forms.
Once your deposit has been accepted, please complete and print out the full application packet (packet will be emailed after submission; it is also available online at cpwestchester.org/summer/).

Pay by credit card below. If you would prefer to pay by check, a printable form is available HERE
Tuition Information
To reserve your spot, we need to receive either a deposit of 50% of the total cost, or payment in full.

Our summer program runs from June 23 – August 1, 2025, Monday – Friday from 9 a.m. to 3 p.m. Additional weeks are available from August 4 – 22, 2025.
- Full tuition for 6-Week Session: $4,000
- Additional weeks: $675 per week
Please contact Kamesha Pollard at 914-937-3800 ext. 640 for more information.
Today's Date

MonthDayYear
Date
Name of Program Participant*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship to Program Participant

MotherFatherOther guardian - please describe
if other, please describe relationship
Phone Number (Home)*
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Phone Number (Cell)
Please enter a valid phone number.
Email Address*
Emergency Contacts & Authorized Pick-Up Person(s)

In addition to parents/guardians
Emergency Contact Name*

First NameLast Name
Relationship to Participant*
Phone Number*
Please enter a valid phone number.
Emergency Contact Name

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Parent/Guardian Agreement
Signature*

Clear
Parent/Guardian Signature

Tuition Information
To reserve your spot, we need to receive either a deposit of 50% of the total cost, or payment in full.

Our summer program runs from June 23 – August 1, 2025, Monday – Friday from 9 a.m. to 3 p.m. Additional weeks are available from August 4 – 22, 2025.
- Full tuition for 6-Week Session: $4,000
- Additional weeks: $675 per week
Please contact Kamesha Pollard at 914-937-3800 ext. 640 for more information.
Pay by credit card below. If you would prefer to pay by check, a printable form is available HERE
Deposit / Tuition *
prevnext( X )
Deposit OnlyAn invoice will be sent for remainder
$2,000.00



Full TuitionRegular session: June 23 - August 1, 2025
$4,000.00



Additional Week 1August 4 - 8, 2025
$675.00



Additional Week 2August 11 - 15, 2025
$675.00



Additional Week 3August 18 - 22, 2025
$675.00



Total

$0.00

Pay with Credit Card

Should be Empty:

Summer Fun Program Registration

Once your deposit has been accepted, please complete and print out the full application packet (packet will be emailed after submission; it is also available online at cpwestchester.org/summer/).

Pay by credit card below. If you would prefer to pay by check, a printable form is available HERE

Tuition Information

Parent/Guardian Information

Emergency Contacts & Authorized Pick-Up Person(s)

Parent/Guardian Agreement

Tuition Information