Name: Preschool Summer Camp
SKU: 31689
Availability: InStock

Preschool Summer Camp

Applicant Information

Applicant Name*

First Last

Preferred Name

Date of Birth*

MM

DD

YYYY

Currently Enrolled at Kings Bay Y?*

Yes
No

Gender*

Male
Female

Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 1*

First Last

Parent/Guardian 1 Occupation

Place of Occupation/Business Name

Parent/Guardian 1 Cell Number*

Parent/Guardian 1 Additional Daytime Number

Parent/Guardian 1 Email Address*

Parent/Guardian 2

First Name Last Name

Parent/Guardian 2 Occupation

Place of Occupation/Business Name

Parent/Guardian 2 Cell Number

Parent/Guardian 2 Additional Daytime Number

Parent/Guardian 2 Email Address

Emergency Contact Name*

First Last

Relationship*

Cell Number*

Applicant Status*

Name of Sibling Applicant*

How did you find out about us?*

Has your child previously been enrolled or is he/she currently enrolled in daycare or preschool?*

No
Yes

If yes, when and where?*

Siblings

List information here for additional children you are enrolling for Summer 2021. You will still need to complete a separate registration for each child you enroll.

Number of Siblings

Sibling 1 Name

First Last

DOB

MM

DD

YYYY

Grade

School

Sibling 2 Name

First Last

DOB

MM

DD

YYYY

Grade

School

Sibling 3 Name

First Last

DOB

MM

DD

YYYY

Grade

School

Scheduling Options

Program Dates: June 28, 2021 - August 20, 2021
Program Hours 8:30AM-4.00PM Monday thru Friday
Extended week: August 23-August 27

Number Of Weeks*

Please enter a number from 1 to 9.

Week Selections*

June 28 - July 2
July 6 - 9 (July 5th - closed for the Independence day observation)
July 12 - 16
July 19 - 23
July 26 - 30
August 2 - 6
August 9 - 13
August 16 - 20

Days Per Week*

5 Days
4 Days
3 Days (M,W,F)
2 Days (T,Th)

Hours*

Half Day (8:30am - 12pm)
Full Day (8:30am - 4pm)

Hours*

Half Day (8:30am - 12pm)
Full Day (8:30am - 4pm)

Hours*

Half Day (8:30am - 12pm)
Full Day (8:30am - 4pm)

Hours*

Half Day (8:30am - 12pm)
Full Day (8:30am - 4pm)

Additional Hours

Early Drop-Off (8-8:30am)
Late Stay (4-6pm)

Additional Hours

Early Drop-Off (8-8:30am)
Late Stay (4-6pm)

Additional Hours

Early Drop-Off (8-8:30am)
Late Stay (4-6pm)

Additional Hours

Early Drop-Off (8-8:30am)
Late Stay (4-6pm)

Total

$0.00

Pickup Authorization

Pick-Up Authorization

Pickup Authorization

We are asking you to complete this form, stating the names of the individuals who are allowed to pick up your child from Kings Bay Y Preschool Summer Camp. Please be as thorough as possible with this list, as we will not allow your child to leave with anyone that isn’t named below. You may add additional names at a later time. Also, please be advised that the person picking up your child must have a valid form of photo ID on them, such as a driver’s license, a passport or current school issued ID. There will be NO exceptions.

I HAVE READ THE ABOVE AUTHORIZATIONS AND AGREE TO ABIDE BY THEM.

Authorized Pickup 1 Name

Relation

Phone Number

Authorized Pickup 2 Name

Relation

Phone

Consent to Photograph, Film or Videotape

Photography Consent

Photo Release

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or videotapes of the Student named above by Kings Bay Y.

I also grant Kings Bay Y the right to edit, use and reuse said products for nonprofit purposes including use in print, on the internet, and all other forms of media.

I also hereby release Kings Bay Y and its agents and employees from all claims, demands and liabilities, whatsoever in connection with the above.

I agree

Downloadable Forms

Medical Authorization Form

Sunscreen Permission Form

Terms & Conditions

Camp payments are due in FULL before your child begins.
Registration fees may not be refunded.
In addition to your registration fee, a service charge of $125 will be incurred for any tuition refunds or cancellations requested on or before June 1st, 2020.
No refunds will be offered after June 1, 2020
Medical forms and immunization records must be completed and submitted prior to the child’s first day of the program.
The  Kings Bay Y will not be responsible for damage to, or loss of, personal property.
Late arrival policy fee: For arrival after designated pickup time, a late fee will be charged.
It is the goal of our program to provide a healthy and safe environment for all participants.  If a participant displays any inappropriate behavior, or endangers the health and safety of participants or staff, we will contact the parent/guardian to immediately come to the site.  We may suspend the participant from the program or consider permanent termination in extreme situations.
Release: I hereby give my permission for my child to participate in all programs, activities and trips.  I understand and fully recognize that risks are involved and I hereby release the Kings Bay Y or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child in the event of a medical emergency or surgical emergency.  I do hereby give authority to the program and staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.  I grant permission to the physician designated by KingsBayY  to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child.  Furthermore, I understand that payment for medical services is solely the family’s responsibility.

I hereby give permission to the Kings Bay YM-YWHA, Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the JCC Brooklyn, a project of the Kings Bay Y.  I release the Kings Bay YM-YWHA, Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication.  I do hereby give permission for my child to participate in all activities, including off-ground activities.  I authorize the Kings Bay YM-YWHA, Inc. to act as a parent surrogate on my behalf.  I realize that itineraries and/or programs are subject to change prior to, and during, the year.

Terms & Conditions

Terms & Conditions can be found here.

Terms & Conditions*

I have read the terms of enrollment and agree to abide by them.

Signature*

Date*

MM

DD

YYYY

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