* Membership:	I am an APJCC member. My membership number is... Note: Your membership number is the number on your membership card that begins with the letter J.  I am a non-member.  JCC Staff
* Parent/Guardian(1):
* Home Phone:
Cell Phone:
Work Phone:
* Address Line 1:
Address Line 2:
* City:
* State:	California Alabama Alaska Arizona Arkansas Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
* Zip:
* Email:
Parent/Guardian(2):
Home Phone:
Cell Phone:
Work Phone:
Address Line 1:
Address Line 2:
City:
State:	California Alabama Alaska Arizona Arkansas Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Email:
* Camper Name (1):
* Child's Birth Date:
* Child's Gender:	Male     Female
Grade in School:	(as of Sept 2010)
School Name:
	Camp Choices You can use this form to register for up to four camps.
#1	* Camp Name: * Session: * Year: * Do you want to sign up for Extended Care? (specify AM, PM, Both, or None) * T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): * Fee:
#2	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size: (specify size 2-4, 6-8, 10-12, or 14-16) Fee:
#3	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#4	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
Camper Name (2):
Child's Birth Date:
Child's Gender:	Male     Female
Grade in School:	(as of Sept 2010)
School Name:
	Camp Choices You can use this form to register for up to four camps.
#1	Camp Name: Session: Do you want to sign up for Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#2	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#3	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#4	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
Camper Name (3):
Child's Birth Date:
Child's Gender:	Male     Female
Grade in School:	(as of Sept 2010)
School Name:
	Camp Choices You can use this form to register for up to four camps.
#1	Camp Name: Session: Do you want to sign up for Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#2	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#3	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
#4	Camp Name: Session: Extended Care? (specify AM, PM, Both, or None) T-Shirt Size (specify size 2-4, 6-8, 10-12, or 14-16): Fee:
Deposit (required deposit is $200 per child for Camp Pashoshim or Camp Katan, or $150 per child for all other camps):	$
Balance due less deposit:	$
* Permission:	I hereby grant permission for my Katan, Yeledim, or Sabra camper to participate in the swim instruction at the APJCC. I hereby grant permission for my Kadima or Madrichim camper to participate in field trips or specialties away from the APJCC. I give permission to the APJCC to authorize any emergency action necessary to ensure the safety of my child. I understand that the APJCC is not financially responsible for medical or emergency care given to my child. I permit free use of our names and/or pictures in broadcasts, newspapers, brochures, or other forms of communication. I accept all financial responsibility for 100% of camp fees. I have enclosed a nonrefundable, nontransferable deposit per session (see fees and deposits) and understand that the balance of payment is due no later than June 4, 2010.
* Payment Info:	I am a JCC member and you have my credit card on file. You have my permission to charge my credit card.

Withdrawal deadline: June 2, 2010
Final Payment deadline: June 4, 2010

Deposit Policy and Refund Policy: Deposits are due upon registration. Deposits are nonrefundable and nontransferable to other APJCC programs and services outside of camp. Balances for all camp programs regardless of session must be paid in full by June 4th, 2010 in order to complete enrollment. The APJCC will not guarantee placement if balances are outstanding after that date. Refunds of camp fees for any session will be granted, less deposit, only if the APJCC is notified in writing of withdrawal prior to June 2nd, 2010. Notification of withdrawal after June 2nd, 2010 will result in a LOSS OF ALL FEES PAID.

Payment Information...

• If you are a Center Member and pay for your membership through automatic billing of your credit card each month, you have the option of paying online by selecting the "Charge my credit card on file" box above. If the JCC has your credit card on file for any other reason, you can also pay online. Make sure you've selected the "Charge my credit card on file" box above, and then press the "Submit Form" button below.