JLounge Registration Application 2025-2026

Dear families,

Please complete this form to begin the J Lounge registration process for the 2025-2026 School Year. Please note that registration is on a space-available basis, and that space is not guaranteed until we collect your payment information and confirm your registration via e-mail.

To view our calendar, including holidays and closures, for the 2025-2026 school year, please click here.

No children will begin care without providing all forms required by the JCC and DHS. These forms are available here or on the JCC's website on the J Lounge page.

You must fill out ONE APPLICATION PER CHILD. If you have more than one child, please submit this application and then re-start a new one for each additional child. A JCC membership is required for JLounge, and enrolled families receive a discounted family membership rate.

General questions about the J Lounge program and registration? Contact Jen Appell, Youth & Camp Assistant Director at jappell@lvjcc.org

Questions about financial aid? Contact Tiffany Miller at tmiller@lvjcc.org. Or call us at 610-435-3571 or drop by any time!

We look forward to seeing you and your children for another great school year!
On This Form:
- Child's Information
- J Lounge Attendance
- Getting to Know Your Child
- Parent/Guardian Information
- Emergency Contact
- Authorized Pickup
- Parental Consent
- Child's Physician/Medical Care Provider
- Health Insurance Info
- Health, TB and Permission to Administer Medication Forms
- Payment Options
- Terms and Conditions
Child Health Forms, TB Forms, and Permission to Administer Medication Forms can be downloaded from the JCC's website at lvjcc.org/jlounge to be filled out and either:

1. Scanned and uploaded at the end of this form prior to submission

2. Turned in directly to Jen Appell, Youth & Camp Assistant Director prior to first day of care
Are you currently a JCC of the Lehigh Valley member?*

YesNo
Is your child a new or returning JLounge student?*

New StudentReturning Student
Referred by
If you were referred to the J Lounge Program by another family, please let us know.
Child's Information
Child's Name*

First NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Grade Entering Fall 2025*
School Entering Fall 2025*
Gender*

MaleFemaleNon-BinaryOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Child Lives With:*

Both ParentsMotherFatherOther
J Lounge Attendance

Please enter the information, including days of the week that J Lounge will be attended by your child. Rates vary based on number of days attended each week and transportation requirements. Please see the full list of pricing: lvjcc.org/jlounge
Intended Start Date

MonthDayYear
Date
Days Attending J Lounge*

MondayTuesdayWednesdayThursdayFriday
Days Needing Transportation*

MondayTuesdayWednesdayThursdayFridayWalking from Muhlenberg Elem.Dropping off at the JCC (arrangements must be made with the JLounge staff)
Getting to Know Your Child
Does your child use a chosen name other than their legal name?
Does your child currently receive special education services, therapies, or other support services?

YesNo
If you answered yes to the previous question, please describe below, and a JCC staff member will contact you to plan a successful afterschool experience for your camper.
What describes your child’s “usual” temperament?

Energy:

	1	2	3

1 is Less Active, 3 is More Active

First reaction to new activities/people:

	1	2	3

1 is Shy, 3 is Jumps Right In

Sensitivity:

	1	2	3

1 is Very Sensitive, 3 is Not Usually Sensitive

Adaptability:

	1	2	3

1 is Adapts Slowly, 3 is Adapts Quickly

Attention Span:

	1	2	3

1 is Easily Distracted, 3 is Stays Focused

What are your child’s current interests & activities?
What activities does your child dislike?
Is there anything else you wish to tell us about your child that will aid in successful afterschool care?
Parent/Guardian (1) Info
Parent/Guardian (1) Name*

First NameLast Name
Parent/Guardian (1) Date of Birth

MonthDayYear
Parent/Guardian (1) Occupation
Parent/Guardian (1) Address (if different than child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian (1) Home Phone

Area CodePhone Number
Parent/Guardian (1) Cell Phone

Area CodePhone Number
Parent/Guardian (1) Business Phone

Area CodePhone Number
Number to Call First:

Cell PhoneHome PhoneBusiness Phone
Parent/Guardian (1) Email*
example@example.com
Parent/Guardian (1) Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian (1) Business Name
Parent/Guardian (2) Info
Parent/Guardian (2) Name

First NameLast Name
Parent/Guardian (2) Date of Birth

MonthDayYear
Parent/Guardian (2) Occupation
Parent/Guardian (2) Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian (2) Home Phone

Area CodePhone Number
Parent/Guardian (2) Cell Phone

Area CodePhone Number
Parent/Guardian (2) Business Phone

Area CodePhone Number
Number to Call First:

Cell PhoneHome PhoneBusiness Phone
Parent/Guardian (2) Email
example@example.com
Parent/Guardian (2) Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian (2) Business Name
Emergency Contact

Please list at least one (other than parent/guardian)
Emergency Contact (1) Name*

First NameLast Name
Relationship to Child*
Number to Call First:

Cell PhoneHome PhoneBusiness Phone
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Business Phone

Area CodePhone Number
Emergency Contact (2) Name

First NameLast Name
Relationship to Child
Number to Call First:

Home PhoneCell PhoneBusiness Phone
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Business Phone

Area CodePhone Number
Authorized Pick-Up

Person(s) to whom child may be released other than parent/guardian
Name

First NameLast Name
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number to Call First:

Home PhoneBusiness PhoneCell Phone
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Business Phone

Area CodePhone Number
Name

First NameLast Name
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number to Call First:

Home PhoneCell PhoneBusiness Phone
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Business Phone

Area CodePhone Number
Parental Consent

Parent/Guardian signature is required for each item below to indicate parental consent. Please note, we will be unable to treat your child if the permission to obtain medical care and permission to administer minor first aid procedures fields are left blank, should either of these situations occur.
Obtain emergency medical care (Initial below)
Administration of minor first aid procedures (Initial below)
Swimming (Initial below)
Transportation (Initial below)
Walking/Field Trips (Initial below)
Child's Physician/Medical Care Provider
Doctor's Name
Office Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Hospital Preference
Health Insurance/Information
Health Insurance Company
Health Insurance Group #
Health Insurance ID#
Does your child have any special physical, educational, emotional, or medical needs or disabilities? If so, please describe in detail so that our staff can provide the best possible care. (All information will remain confidential)
List any allergies and/or reactions (including medication reaction)
Does your child take any regular medications?
Include any medical or dietary information necessary in an emergency situation
List any permanent birthmarks or other physical markings (i.e. hemangioma)
Does your child experience any of the following:

Frequent HeadachesFrequent Stomach AchesNone of These
Additional information on special needs of child
Please submit your child's Health, TB, and Permission to Administer Medication forms.

One submission must be made per child. If you have hard copy forms, they may be turned in to Alaina Schaeffer, Youth and Camp Assistant Director, at the JCC.
Download blank forms:

Child Health Form | Download

Allentown Tuberculosis Form | Download
Both physician's signature and office stamp are required in order for this form to be considered valid.

Permission to Administer Medication | Download
Upload Your Health Form

Browse Files

Cancelof
Upload Your TB Form

Browse Files

Cancelof
Upload Your Permission to Administer Medication Form

Browse Files

Cancelof
Payment Options
Are you applying for financial aid? (Skip if not applicable)

Financial Aid/Flexible TuitionChild Care Works/ELRC ("Title XX")
Your credit card will be charged the $200 deposit fee per child. (Your monthly J Lounge tuition fees will be charged or bank drafted using your JCC membership account information.) This non-refundable fee will be applied to your first months tuition payment.
Payment Method

Please charge my card on file.Please contact me for payment information
J Lounge Terms and Conditions
Today's Date

MonthDayYear
READ THE FOLLOWING BEFORE SIGNING:

Terms of Use

Membership Agreement

Payment & Refund Policy

Waiver, Release and Indemnification Agreement

Child Care Parent Agreement

Guest Pass Policy
By signing below, I accept the terms of the JCC's Membership Agreement (link above). I understand that I will be charged a monthly membership fee based on my membership type, which will automatically renew each month until I cancel it. Membership fees may change from time and time, with new fees being communicated via e-mail to the address you have provided. To cancel your membership, you can do so in person or on the phone (610-435-3571) during regular business hours, via e-mail (tsussman@lvjcc.org), or via the Daxko online portal. Membership must be canceled with a minimum two (2) business days' notice prior to the next billing date.*

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By signing, I acknowledge that I have read and completed this form accurately and in its entirety.
By signing below, I acknowledge that I have read, understand and accept the Terms of Use, Membership Agreement, Payment & Refund Policy, Waiver, Release and Indemnification Agreement, Child Care Parent Agreement, and Guest Pass Policy.*

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By signing, I acknowledge that I have read and completed this form accurately and in its entirety.
Should be Empty:

Child's Information

J Lounge Attendance

Getting to Know Your Child

Parent/Guardian (1) Info

Parent/Guardian (2) Info

Emergency Contact

Authorized Pick-Up

Parental Consent

Child's Physician/Medical Care Provider

Health Insurance/Information

Please submit your child's Health, TB, and Permission to Administer Medication forms.

Payment Options

J Lounge Terms and Conditions