Rosen JCC: Early Childhood School, Camp, and Membership Application (School Year 2019-2020)

Rosen JCC: Early Childhood School, Camp, and Membership Application (School Year 2019-2020)
Dear parents,

It's that time of the year again! Please complete this form to begin the Early Childhood registration process for the 2019-2020 School Year. Please note that registration is on a space-available basis, and that space is not guaranteed until we receive your VPK certificate (if applicable) and registration fee.

To view our programs, rates and the full calendar for the 2019-2020 school year, please click here.

The registration process is not complete until you have submitted all required forms. No children will be admitted to begin school until the following documents are received by the JCC, including; emergency information, immunization form, health documentation, and financial arrangements required by DCF regulations.

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.

Questions? Contact Jill Schwartz, Early Child Office Manager, at JillS@rosenjcc.org or 407-239-7411.

Are you a current member of the Rosen JCC? *

Yes No
Which program will your child attend? *

12-months (June 1-May 31) 10-months (August 1-May 30)
Child's Name *

First Name Last Name
Current Classroom *
If you are registering a new student who is not currently enrolled in the Early Childhood program, please select Not Currently Enrolled. If you are re-registering a student who IS currently enrolled in the Early Childhood program, please select their current classroom.
Gender *

Male Female
Cutoff Date

- Month - Day Year
Birthdate *

- Month - Day Year Date Picker Icon
Age as of 9/1/19
This is calculated automatically based on the birthdate above.
Allergies/Special Needs *
If none, please enter "None" in the box.

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

- Area Code Phone Number
Family Religion(s) *

Jewish Catholic Muslim Protestant Hindu Buddhist None
Parent 1 Name *

First Name Last Name
Parent 1 Birthdate *

- Month - Day Year
Date Date Picker Icon
Relation to Child *
Parent 1 Cell Phone *

- Area Code Phone Number
Parent 1 E-mail *
Parent 1 Occupation *
Parent 1 Employer
If there are two parents, do they live together? *

Parents live together Parents live apart Only 1 parent
Parent 2 Name

First Name Last Name
Parent 2 Birthdate

- Month - Day Year
Date Date Picker Icon
Relation to Child

Parent 2 Cell Phone

- Area Code Phone Number
Parent 2 E-mail
Parent 2 Occupation
Parent 2 Employer
What is the relationship between the two parents?

Married/Partners Divorced/Separated Widowed
What are you registering for? *

Camp + School (12-month program) School ONLY (10-month program) Camp ONLY (2-month program) [June 4-August 27]
Which weeks are you attending?

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
Program *

Noah's Ark - 2 months by 9/1/19 (only available for eight weeks) Toddlers - 12 months by 9/1/19 Twos - 2 years by 9/1/19 Threes - 3 years by 9/1/19 Pre-K/VPK - 4 years by 9/1/19 Rising Pre-K (Summer Only) - 5 years by 9/1/19
Intended Start Date

- Month - Day Year Date Picker Icon
Program Hours (Toddlers & Twos)

5 days (Mon-Fri), 9am-12:30pm 5 days (Mon-Fri), 9am-3pm 5 days (Mon-Fri), 7am-6:30pm 3 days (M/W/F), 9am-3pm 3 days (M/W/F), 7am-6:30pm 2 days (Tu/Th), 9am-3pm 2 days (Tu/Th), 7am-6:30pm
Program Hours (Threes)

5 days (Mon-Fri), 9am-3pm 5 days (Mon-Fri), 7am-6:30pm 3 days (M/W/F), 9am-3pm 3 days (M/W/F), 7am-6:30pm 2 days (Tu/Th), 9am-3pm 2 days (Tu/Th), 7am-6:30pm
Program Hours (Pre-K)

5 days (Mon-Fri), 9am-3pm 5 days (Mon-Fri), 7am-6:30pm 5 days (Mon-Fri), 9am-12pm (VPK only) 5 days (Mon-Fri), 12pm-3pm (VPK only)
Do you want your child to nap?

Yes No
Do you need extended care from 8-9 a.m.?

Yes ($100/month) No
Teacher Appreciation Fund

Families are encouraged to participate in our Family Appreciation Fund, which is used to provide holiday gifts, gift cards, meals and events in appreciation of our teachers. By checking this box, I understand I will be charged $50 per child in August and $50 per child in October for this fund. Participation is optional.
Please read and check each item. *
Registration Fee *

Returning Families and New Siblings - $150 (until April 1) New Families and Returning Families that register after April 1 - $250 (Annual Registration Fee)
Employee Code
If given an Employee Code, enter it here. Otherwise, leave this blank.
By signing below, I agree that I have read and understand the terms of ECLC enrollment, the Membership Agreement and the Waiver, Release and Indemnification Agreement. *
Today's Date

- Month - Day Year
Additional Comments
Should be Empty: