Register for Winter Camp J 2023 How many campers are you registering for Winter Camp J?*1234Camper InformationCamper #1Camper’s Legal Name* First Last Camper’s Chosen Name Camper’s Pronouns Camper’s Date of Birth* MM slash DD slash YYYY Camper’s Current Grade*Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th GradeCamper 1 Camp Type*Select Camp TypeWinter Camp (grades K-5th)Siyur Winter Camp (grades 6th-9th)Siyur Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 (Overnight) Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 (Overnight) Thursday, January 4 Friday, January 5 Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 Thursday, January 4 Friday, January 5 Who does this child reside with? Does this camper receive any support services (OT, PT, Special Education, etc.) or is a client with DDD?*NoYesDoes this camper have any sensory sensitivities? What do big emotions look like in this camper? How can camp best support this camper during a big emotion? Is there any other information you would like camp to know about this camper? Camper #2Camper’s Legal Name* First Last Camper’s Chosen Name Camper’s Pronouns Date of Birth (Child 2) MM slash DD slash YYYY Camper’s Current Grade*Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th GradeCamper 2 Camp Type*Select Camp TypeWinter Camp (grades K-5th)Siyur Winter Camp (grades 6th-9th)Siyur Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 (Overnight) Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 (Overnight) Thursday, January 4 Friday, January 5 Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 Thursday, January 4 Friday, January 5 Who does this child reside with? (Camper 2) Does this camper receive any support services (OT, PT, Special Education, etc.) or is a client with DDD?*NoYesDoes this camper have any sensory sensitivities? What do big emotions look like in this camper? How can camp best support this camper during a big emotion? Is there any other information you would like camp to know about this camper? Camper #3Camper’s Legal Name* First Last Camper’s Chosen Name Camper’s Pronouns Date of Birth (Camper 3) MM slash DD slash YYYY Camper’s Current Grade*Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th GradeCamper 3 Camp Type*Select Camp TypeWinter Camp (grades K-5th)Siyur Winter Camp (grades 6th-9th)Siyur Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 (Overnight) Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 (Overnight) Thursday, January 4 Friday, January 5 Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 Thursday, January 4 Friday, January 5 Who does this child reside with? (Camper 3) Does this camper receive any support services (OT, PT, Special Education, etc.) or is a client with DDD?*NoYesDoes this camper have any sensory sensitivities? What do big emotions look like in this camper? How can camp best support this camper during a big emotion? Is there any other information you would like camp to know about this camper? Camper #4Camper’s Legal Name* First Last Camper’s Chosen Name Camper’s Pronouns Date of Birth (Camper 4) MM slash DD slash YYYY Camper’s Current Grade*Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th GradeCamper 4 Camp Type*Select Camp TypeWinter Camp (grades K-5th)Siyur Winter Camp (grades 6th-9th)Siyur Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 (Overnight) Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 (Overnight) Thursday, January 4 Friday, January 5 Winter Camp Dates*Please select every day you wish to register this child for. Select All Tuesday, December 26 Wednesday, December 27 Thursday, December 28 Friday, December 29 Tuesday, January 2 Wednesday, January 3 Thursday, January 4 Friday, January 5 Who does this child reside with? (Camper 4) Does this camper receive any support services (OT, PT, Special Education, etc.) or is a client with DDD?*NoYesDoes this camper have any sensory sensitivities? What do big emotions look like in this camper? How can camp best support this camper during a big emotion? Is there any other information you would like camp to know about this camper? Grown-up InformationGrown-Up #1Grown-Up’s Name* First Last Grown-Up’s Pronouns Are you a member of the J?*-YesNoGrown-Up’s Email* Grown-Up’s Phone*Grown-Up’s Residential Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you want to provide information for a second Grown-Up?NoYesGrown-Up #2Grown-Up #2 Name* First Last Grown-Up #2: Are you a member of the JCC?-YesNoGrown-Up #2 Email* Grown-Up #2 Phone*Grown-Up’s Residential Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country *leave blank if same as Parent #1Misc QuestionsDo you currently receive scholarship from the J?NoYesAre you receiving DES?NoYesWould you like to make a tax-deductible donation to help send a kid to camp?YesNoHow much would you like to donate? $18 $36 $54 Payment, Cancellation, and Program PoliciesHow would you like to pay?Card # on file with the JCredit CardCheckCard # on file with the JLast four digits of card # on file* Credit CardName on Card* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Credit Card Type*VisaMaster CardDiscover*We do not accept American Express* Card Number* Spaces and dashes are not required. Card will not be charged until their camper is actively registered by Director of Camping ServicesLast Four Digits* *Answer should match the last 4 number on the card aboveCVV (3-digit code on back of card)* Card Expiration Date* Input format: mmyy (Example: 0325)CheckUpload a Photo of a Void Check*Max. file size: 50 MB.Payment PolicyRates are based on campers’ membership status at time of registration. Membership must remain active and in good standing throughout time registered. Payment is required in full upon registration. Cancellation policy: More than 2-weeks notice - refund all camp fees. Less than 2-weeks notice - refund 50% of camp fees. Less than 24 hours notice, no refunds. This registration form will be emailed directly to the Camp Director and they will register your campers. Payment option must be submitted with registration. Camp will send an email confirmation with other required forms. All schedules and programs are subject to change. Your signature below acknowledges that you understand the refund/cancellation policy. As a parent and/or guardian, I assume all risks (injury or illness) for my children and family members that may occur during participation in any activities or use of facilities at The J or on supervised field trips. In case of sudden injury or illness, I hereby give authority to any hospital or doctor to render immediate aid as may be required the time for my child’s health and safety. I hereby give permission for J personnel to use their judgment in arranging for my child’s emergency medical treatment in addition to contacting me to the best of their ability. I certify that my child is fully covered by medical insurance and that I am fully responsible for all costs incurred due to medical or dental treatment as deemed necessary by J personnel. I understand medical expenses are my responsibility. I authorize staff to apply sunscreen to avoid sunburn. I give permission for my child to swim in The J pool, for my child to attend J supervised field trips, and for photographs to be taken and used privately and/or in J publications and advertising. By signing this form, I acknowledge that I am aware of the potential risks of participating in activities and/or programs at The J, and agree to in no way hold the management, agent or employees of the J liable for any injury that my children may sustain.Immunization PolicyImmunization Agreement*For the health, safety, and welfare of both the staff and students, the Tucson JCC follows all the Department of Health Services vaccination requirements for students entering our program. Documentation of compliance, from an M.D. OR D.O., with these requirements shall be provided to the center. There are no religious or personal exemptions to this policy. I have read and understood the above policies.Digital Signature* First Last Today's Date* MM slash DD slash YYYY