Registration

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Please complete the form below to begin the registration process. When finished, click Submit and a PDF (Adobe Acrobat file) will be generated in a new window. This file should be printed, signed and mailed to the local JCYS address listed. You will receive an email linking you back to the completed PDF so you may print the file at a later date if necessary. If you are registering for more than one child simply close the PDF window after completing the first registration, return to this page to make the necessary edits. Click submit, once again, and a NEW PDF will be generated for an additional child. Thank you for registering at JCYS.

Summer Camp 2006: June 26-August 18
Half Day	TTh MWF MTWThF
Full Day	MWF MTWThF
Fall/Winter Camp 2006/07: Aug 31-June 15, 2007
Half Day	TTh MWF MTWThF
Full Day	MWF MTWThF
Child Information
Child's Name
Sex	M F
Birth date
Street Address
City
State
Zip
Family Information
Contact E-Mail*
Mother/Guardian
Address
City
State
Zip
Home Phone
Work Phone
Cell
Father/Guardian
Address
City
State
Zip
Home Phone
Work Phone
Cell
Marital Status	Married Divorced Separated Single Parent Remarried Other
Employment Status	One Parent/Guardian Works Both Parents/Guardians Work
Emergency Information
Name
Relationship
Home Phone
Work Phone
Cell
Name
Relationship
Home Phone
Work Phone
Cell
Child's Doctor
Doctor's Phone
I would like to apply for financial assistance	Yes No
Billing Information
Name
Address
City, St, Zip
Home Phone
Work Phone