JA BizTown Summer Camp 2015
Gene B. Glick Junior Achievement Education Center
7435 N. Keystone Ave. Indianapolis, IN 46240
317-252-5900 ext. 6 or Fax # 317-218-3493
Child’s Name Male______Female ______
Child’s Age Grade 2014-15School Year Child’s School ______
Child’s Ethnic Origin ___ Asian ___ American Indian or Alaskan Native ___ Black/ African American ___ Hispanic/ Latino ___ Native Hawaiian/ Other Pacific Islander ___ White ___ Other ______
All children receive a JA BizTown Summer Camp T-Shirt with Registration: Adult Sizes: S M L XL XXL
List any Health or Medical Conditions that your child may have: ______
How did you hear of our summer camp program? __School ___Attended Camp Last Year ___Friend/Family ___Website ___@ the Facility ___Indy’s Child ___E-Mail Ad ___Newspaper Ad ____Radio Disney ___Other ______
Parent or Guardian Name/s______
Street AddressCityStateZip______
Phone Numbers: 1. ( )______2. ( )______
Your child will not be released to any individual whose name does not appear on this list – NO EXCEPTIONS. Please list individualsother than the parent/guardian,who can be reached in case of an emergencyor have the authority to pick your child up from camp.
Name PhonePhone_____EC
Name Phone Phone_____EC
CAMP DATES (Select one): June 15-19 June 22-26 July 13-17 July 20-24
Option 1 - Regular Camp 9:00am – 4:00pm$175.50 per camper (Early Bird Special)_____
Option 2 - Extended Camp8:00am – 5:30pm$225 per camper (Early Bird Special) _____
Option 3- Regular Camp for Sibling$160 per camper_____
Option 4- Extended Camp for Sibling$210 per camper_____
Pizza Option (available on Friday only. 1 Pizza slice = ¼ Pizza)$ 2 per slice/per camper_____
(All campers must bring their own lunch Monday – Thursday)Total_____
___ Check enclosed for $ (payable to Junior Achievement) OR___ Visa___ MasterCard ___American Express___Discover
Credit Card Number______Exp. Date__Signature of Card Holder______
MEDICAL RELEASE:
The undersigned hereby authorizes officials of Junior Achievementto contact directly those individuals named as emergency contacts as may be deemed necessary in their judgment, for the health of the child described in this registration.I hereby release and discharge Junior Achievement of Central Indiana, Inc.from any and all financial responsibility for medical care and/or transportation of such child to receive medical care.I agree to indemnify and hold harmless Junior Achievement of Central Indiana, Inc. from any and all claims, damages, costs, attorney’s fees or damages of any kind arising out of participation in camp.
Photo / Video Policy - Unless stated otherwise in writing by the parent or guardian and received by Junior Achievement, your child may bephotographed during JA BizTown Summer Camp foruseon theJAwebsite, JApromotional literature or any CD/DVD.
Signature of Parent/Guardian: ______Date: ______
EMAIL CONFIRMATIONS SHOULD BE SENT HERE (Please Print Clearly):______@______
Junior Achievement of Central Indiana Federal Tax ID Number: 35-1003695Generously Sponsored By: