AJCC ECE Preschool Summer Application

Child’s Name *

First

Last

Birthdate *//

Parent/Guardian Names *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Phone #2

Email *

Email #2

AJCC Membership is required to enroll in the ECE. Are you an AJCC Member? *

YES
NO

Please select the schedule that you are interested in *

3-Day (Mon, Wed, Fri)
5-Day (Monday-Friday)

What 3-day program works for you? *

Preschool- 9:00am-1:00pm
Preschool Plus- 9:00am-2:30pm

What 5-day program works for you? *

Preschool- 9:00am-1:00pm
Preschool Plus- 9:00am-2:30pm

Thank you for selecting our 3 Day 9 AM- 1 PM program. What months are you interested in? *

JUNE (June 8th-July 3rd) $150 per week / $600 a month
JULY (July 6th-July 31st) $150 per week / $600 a month
AUGUST (August 3-August 28th) $150 per week / $600 a month

Thank you for selecting our 3 Day 9 AM- 2:30 PM program. What months are you interested in? *

JUNE (June 8th-July 3rd) $200 per week / $800 a month
JULY (July 6th-July 31st) $200 per week / $800 a month
AUGUST (August 3-August 28th) $200 per week / $800 a month

Thank you for selecting our 5 Day 9 AM- 1 PM program. What months are you interested in? *

JUNE (June 8th-July 3rd) $213 per week / $850 a month
JULY (July 6th-July 31st) $213 per week / $850 a month
AUGUST (August 3-August 28th) $213 per week / $850 a month

Thank you for selecting our 5 Day 9 AM- 2:30 PM program. What months are you interested in? *

JUNE (June 8th-July 3rd) $285 per week / $1,140 a month
JULY (July 6th-July 31st) $285 per week / $1,140 a month
AUGUST (August 3-August 28th) $285 per week / $1,140 a month

Total

$ 0.00

Start dates other than the 1st day of the month will be prorated accordingly

Payment details *

I would like to make my payment in Full (payment will be processed JUNE 5th)
I would like to make payments processed at the beginning of every month (JUNE/JULY/AUGUST)

Please note: the first payment will be processed on June 5th. The July and August payments will be processed on the 1st.

Please Note:

A non-refundable and non-transferable summer registration fee of $175 will be processed at the time of registration.

How would you like to pay? *

Credit Card
EFT (attach voided check)
Payroll deduction (AJCC STAFF ONLY)

If you have a change of payment information please contact Rachel Gordon at rgordon@alpertjcc.org

Name on Credit Card: *

Last 4 digits for card on file *

Exp. *

Upload image of a voided check below *

Click or drag a file to this area to upload.

I would like to contribute a one-time additional donation to help a child attend the ECE in the amount of....

By signing this form, I agree to the following conditions:

Registration fee is non-refundable and non-transferable. *

Please enroll my child as indicated by the above selections. *

Proof of immunization is necessary for my child to start the program and must be updated annually. Children's immunization records must be turned in within the first 30 days of your child beginning the Summer 2020 session. *

Upload immunization records below

Click or drag a file to this area to upload.

To be eligible for member rates, AJCC membership dues must be current throughout the time for which the child is registered. *

I understand I have 48 hrs days after confirmation of enrollment to withdraw without penalty. After this period, I understand I am responsible to pay the tuition for the remaining contract year or until my child’s spot is filled (with a minimum of a one (1) month penalty). *

There will be a $50 charge for NSF checks that are returned to the JCC. *

We reserve the right to withhold services. The applicant agrees to abide by all rules and regulations of the Alpert JCC and I understand that failure to act in accordance with the rules may result in expulsion from the Alpert ECE with no refund. *

Tuition payment is required regardless of absence including, but not limited to, vacation, illness or unforeseen closure. *

I understand that I am responsible for tuition payments outlined in this contract and that I am responsible for providing the AJCC with updated payment information if necessary. I understand that if any past due payments are not paid within 48 hours of notification services will be suspended or terminated. *

I understand that late charges will be charged as incurred. *

Participation in AJCC activities constitutes permission for the agency to use any photos or videos of the participants for promotional purposes, without remuneration.

Please do NOT use my child's photo for any promotional purposes.

Please do NOT use my child's photo for any promotional purposes.

Morning/Afternoon snack & lunches will be brought from home and follow healthy food and licensing guidelines. No food will be provided on site. *

Food Sensitivities/Allergies

I understand that the ECE does not allow outside food for celebrations, birthdays, etc unless they are pre-packaged, sealed with ingredient label, and are approved in advance and signed-off by the ECE Director. *

I understand that the ECE can change the food policy at any time based on need. *

Coronavirus / COVID-19 Warning & Disclaimer: Coronavirus a/k/a COVID-19 is an extremely contagious virus that spreads easily through person-to-person or other contact. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in programs or activities upon the AJCC ECE premises could increase the risk of contracting COVID-19. The AJCC ECE in no way warrants that COVID-19 infection will not occur through participation in programs or activities upon the AJCC ECE premises. I hereby certify that I have full knowledge of the nature and extent of the risks inherent in my and my child’s entry upon the AJCC ECE premises, the use of any of the AJCC ECE’s facilities or equipment, and my child’s participation in any of the AJCC ECE’s programs and that I am voluntarily assuming said risks. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, or death, I sustain as a result of my entry upon the AJCC ECE premises, the use of any of the AJCC ECE’s facilities or equipment, and/or my participation in any of the AJCC ECE’s programs and that by signing this agreement I HEREBY RELEASE THE AJCC ECE from all liability for such loss, damage, or death. I further certify that my child is in in good health and has no conditions or impairments which would preclude their safe entry upon the AJCC ECE premises, the use of any of the AJCC ECE’s facilities or equipment, and/or their participation in any of the AJCC ECE’s programs.

By signing below I understand and agree that I am financially responsible for payment. I understand that delinquent payments not paid within 48 hours of notification will result in suspension or termination of services. *

Parent/Guardian Signature

Date *//

Parent/Guardian Signature

Date//

For students who will be 3 yrs old on 9/1/2020

Thank you for your interest in our AJCC ECE, we are looking forward to a great summer! Please Note: This application does not confirm acceptance, we will contact you by May 29th with an update on your enrollment status.

Please Note:

By signing this form, I agree to the following conditions:

Food Sensitivities/Allergies

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