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					                                            2011 - 2012 Registration Form
  1. Child’s Name _____________________________Please Check:                                        Male     Female
  Date of Birth __________________:
  Toddler:                   Age as of 9/1/11: ___yr____months
  2 yr old – K:              Age as of 10/1/11: ___yr____months
  Family Name:_________________________ Home Phone #: __________________
  Address _____________________________ Town ____________Zip Code_______
  Guardian 1 Name _________________________________________________
  Work Phone #________________________Cell Phone# ________________
  Email____________________________________
  Guardian 2 Name _________________________________________________
  Work Phone #________________________Cell Phone# ________________
  Email____________________________________

  2. Please Select Days (Kindergarten and Kindergarten Enrichment are ONLY 5 day programs):
  School:     Mon    Tue      Wed       Thur      Fri
  Camp:       Mon    Tue      Wed       Thur      Fri
                                                    Tuition Prices are for a 10 month school Year (Sept2011-June2012)
      3. Please Circle Number of Days Attending:                     2 days           3 days            4 days         5 days
       Circle the appropriate tuition price for program(s) in       Available for
                                                                     2 yr olds
                     the corresponding column
                                                                         only

      Half Day              9am-12:30pm                             $2,856          $4,060            $5,100          $5,865

      Full Day          9am-3pm                                     $4,590          $6,426            $8,150          $9,170
      Extended Day      7:30am-6:00pm                               $5,763          $8,364            $11,118         $12,852
      Early Care        7:30am-8:45am                               $990            $1,448            $1,887          $2,315
      Late Stay         3pm-6pm                                     $1,071          $1,581            $2,050          $2,519
      Extended Late Stay 6pm-6:30pm – No Fridays (min 5 kids)       $200            $270              $360                ----
      Infant/Toddler Program           7:30am-6pm                       ----        $11,004           $14,260         $16,769
                                                                                    for 12 months     for 12 months   for 12 months

      Infant/Toddler Program           9am-12pm                         ----        $4,406            $5,447          $6,610
                                                                                    for 12 months     for 12 months   for 12 months
      Full Day Kindergarten - *Late Stay Available thru J CREW          ----            ----               ----       $9,170
      Kindergarten Enrichment – non-members add $670                    ----            ----               ----       $4,784
      Add Camp - Half Day (Not available for Kindergarten)          $795            $1,285            $1,760          $2,215
NEW
      6/27-8/26/11 (9 weeks, for the price of 8)
      9am-12:30pm (AM Transportation Included)
      Add Camp -Full Day 6/27-8/26/11 (9 weeks, for the                 ----        $2,215            $2,660          $2,900
      price of 8) 9am – 4pm (AM&PM Transportation Included)
      Add Camp Early Care 7:30am-8:45am                                 ----        $195              $255            $315
      Add Camp Late Stay 4-6pm                                          ----        $275              $370            $450
      Add Extended Late Stay 6pm-6:30pm –No Fridays (min 5 kids)        ----        $54               $72                ----
      Total
         Terms of Enrollment for 10 month programs – Extremely Important!
                                      September 2011 – June 2012

1.    All payments are due in full per the payment schedule; all late payments are subject to a late charge of
      $100.There is a $30 charge for all returned checks.
2.    The age of your child as of October 1, 2011 determines which class your child will be in for the 2 year old –
      Kindergarten programs.
3.    The age of your child as of September 1, 2011 determines which class your child will be for the 15 month – 24-
      month program.
4.    In accepting a child’s enrollment, we reserve a place for him/her. If for any reason you cancel an enrollment,
      the following rules will apply:
           Cancellations prior to March 1, 2011, you will be refunded all school fees paid, less $150.00 per child.
           There will be no refunds for any cancellation after March 1, 2011, no exceptions! This includes
               enrollment changes that result in a decrease in the number of days you will be attending.
5.    There are no refunds or credits due to illness, absence, epidemic, suspension or emergency closing.
6.    First change to your child’s schedule is free. Any changes to their schedule after that are subject to a $25
      administration fee per change.
7.    All sessions require a 10% deposit, due at the time of registration. Your 10% deposit must correspond to 75%
      of your current total tuition at ALL times.
8.    Your JCC Membership must remain current throughout the 10 months.
9.    Membership is not required to be in our Kindergarten Enrichment program; however there is an additional
      tuition fee of $670.
10.   Preschool administration reserves the right to place your child in a class they deem appropriate, as well as ask
      that you withdraw any child whom we deem unable to maintain a safe relationship within the confines of our
      program.
11.   Early drop off and late stay are offered at supplementary fees and parents will be billed an additional
      $10/every 15 minutes, beginning 5 minutes after the late stay pickup time.
12.   *Kindergarten Late Stay available through JCC’s J CREW Program. Separate Registration Form available.
13.   The JCC’s insurance policy is secondary to your family insurance policy.
14.   Students will not be admitted to school unless all forms have been completely and properly filled out before
      the start of the program. (August 15th)
15.   Sibling discount - $50 one time fee will be deducted from the balance due.
16.   Any child registering for a 3-year-old class or older must be potty trained by September 1, 2011.
17.   Preschool reserves the right, in its sole discretion, to suspend or dismiss any child if his or her conduct is
      detrimental to the well being of the preschool or of any other children(s) and no refunds or credits will be
      issued.
18.   Preschool may photograph and video my child and use these images for brochures, websites, promotional,
      and/or advertising purposes (no names will be used).
19.   Child’s family contact information on class lists and other similar formats may be shared with other families
      solely for the personal use of such families.
20.   Should you decide to terminate your child’s registration at the Blaustein Early Childhood Center, you must give
      30 days written notice. If proper written notice is not given, you will be charged for the subsequent month.
21.   The JCC reserves the right to change / adjust this form and terms of enrollment policies.

I have read and agreed to the rules of enrollment. I release the Blaustein Early Center and the Shimon and Sara
Birnbaum Jewish Community Center from any and all liabilities. In the event that you cannot be contacted in a
medical emergency, you hereby grant your permission to the Shimon and Sara Birnbaum JCC to take your child to
the nearest medical facility to provide a physician and to give emergency treatment to your child.

Signature of Parent/Guardian____________________________ Date ______________
         Terms of Enrollment for 12 month programs – Extremely Important!
                                           July 2011 – June 2012

1.    All payments are due in full per the payment schedule; all late payments are subject to a late charge of
      $100.There is a $30 charge for all returned checks.
2.    In accepting a child’s enrollment, we reserve a place for him/her. If for any reason you cancel an enrollment,
      the following rules will apply:
            Cancellations prior to March 1, 2011, you will be refunded all school/camp fees paid, less $150.00 per
               child.
            There will be no refunds for any cancellation after March 1, 2011, no exceptions! This includes
               enrollment changes that result in a decrease in the number of days you will be attending.
3.    There are no refunds or credits due to illness, absence, epidemic, suspension or emergency closing.
4.    First change to your child’s schedule is free. Any changes to their schedule after that are subject to a $25
      administration fee per change.
5.    All sessions require a 10% deposit, due at the time of registration. Your 10% deposit must correspond to 75%
      of your current total tuition at ALL times.
6.    Your JCC Membership must remain current throughout the year.
7.    Membership is not required to be in our Kindergarten Enrichment program; however there is an additional
      tuition fee of $670.
8.    Preschool/Camp administration reserves the right to place your child in a class/group they deem appropriate,
      as well as ask that you withdraw any child whom we deem unable to maintain a safe relationship within the
      confines of our program.
9.    Early drop off and late stay are offered at supplementary fees and parents will be billed an additional
      $10/every 15 minutes, beginning 5 minutes after the late stay pickup time.
10.   *Kindergarten Late Stay available through JCC’s J CREW Program. Separate Registration Form available.
11.   The JCC’s insurance policy is secondary to your family insurance policy.
12.   Students/Campers will not be admitted to school/camp unless all forms have been completely and properly
      filled out before the start of the program.
13.   Sibling discount - $150 one time fee will be deducted from the balance due.
14.   Please note that should transportation prices for camp rise significantly, we reserve the right with notification,
      to add a transportation surcharge to alleviate such charges.
15.   Preschool/Camp reserves the right, in its sole discretion, to suspend or dismiss any child if his or her conduct
      is detrimental to the well being of the preschool or of any other children(s) and no refunds or credits will be
      issued.
16.   Preschool/Camp may photograph and video my child and use these images for brochures, websites, promotional,
      and/or advertising purposes (no names will be used).
17.   Child’s family contact information on class lists and other similar formats may be shared with other families
      solely for the personal use of such families.
18.   All dates are subject to change when school closings are finalized.
19.   Should you decide to terminate your child’s registration at the Blaustein Early Childhood Center, you must give
      30 days written notice. If proper written notice is not given, you will be charged for the subsequent month.
20.   The JCC reserves the right to change / adjust this form and terms of enrollment policies.

I have read and agreed to the rules of enrollment. I release the Blaustein Early Center, Camp Ruach and the
Shimon and Sara Birnbaum Jewish Community Center from any and all liabilities. In the event that you cannot be
contacted in a medical emergency, you hereby grant your permission to the Shimon and Sara Birnbaum JCC to take
your child to the nearest medical facility to provide a physician and to give emergency treatment to your child.

Signature of Parent/Guardian____________________________ Date ______________
   4. Membership Information (Please X box):
   Families enrolled in our programs need to be JCC members with the exception of Kindergarten Enrichment.
   2 Parent Family:
       Basic Dues$845: Include: Gymnasium, Indoor Pool, Fitness Center and all Programs at member rates.
       STAR Dues $1,295: Includes use of BASIC plus both summer swim club and Unlimited Group Fitness Classes.
   Single Parent Family (only available to single parent families)
       Basic Dues $640: Include: Gymnasium, Indoor Pool, Fitness Center and all Programs at member rates.
       STAR Dues $1,090: Includes use of BASIC plus both summer swim club and Unlimited Group Fitness Classes.
   Please X Box
       I am already a JCC member and will make sure my membership is current throughout the year.
       Start my NEW JCC membership today __________.
       Please wait to process my NEW JCC membership until my child’s program begins______________
NEW 5.   Tuition Schedule Information (Please X Box)
         Pay in full
         Pay Quarterly
         Pay Monthly
   6. Select
         Check # ______
         Credit Card __ Amex __ Visa __MasterCard
         CC# ____________________________ Exp _______
   7. Deposit
   Refer to step 3 Total on first page
      10% deposit for 10 month program = $_______________
      10% deposit for 12 month program = $_______________
   Your 10% deposit must reflect 75% of your current tuition at ALL times
   Deposit = ________ + Membership Dues _______ =Total Enclosed ________

   8. PAYMENT POLICIES AND SELECTION

   ___OPTION #1 I authorize the JCC to charge my child’s tuition fees according to the schedule
         Please circle one: Visa    American Express          MasterCard
         Credit Card # ____________________________ Expiration Date _________________
         Signature ________________________________

   ___OPTION #2 I authorize the JCC to debit my checking account according to the schedule
       Please attach a voided check.

   ___OPTION #3 I choose to pay by check. Attached are the REQUIRED post dated checks.

   I hereby have read and understand the terms of enrollment as stated above.

   __________________________________                         __________________
   Signature of Parent/Guardian                               Date

				
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