JA BizTown Summer Camp 2024

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2024 JA BizTown Summer Camp Registration Form

Junior Achievement of Central Indiana, Inc.

7435 N. Keystone Avenue

Indianapolis, IN 46240

How did you hear about JA BizTown Summer Camp?

Camper Information

Child #1*

First Name

Last Name

Child #2

First Name

Last Name

Child #3

First Name

Last Name

Child #1 is a *

Boy Girl

Child #2 is a

Boy Girl

Child #3 is a

Boy Girl

Child #1 Age*

Child #2 Age

Child #3 Age

Child #1 Grade Completed During 2023-24 School Year*

Child #2 Grade Completed During 2023-24 School Year

Child #3 Grade Completed During 2023-24 School Year

School Child #1 attends:*

School Child #2 attends:

School Child #3 attends:

T-Shirt Size (Adult Sizes!) Child #1*

all children receive a JA BizTown Summer Camp T-Shirt with registration

T-Shirt Size (Adult Sizes!) Child #2

all children receive a JA BizTown Summer Camp T-Shirt with registration

T-Shirt Size (Adult Sizes!) Child #3

all children receive a JA BizTown Summer Camp T-Shirt with registration

List any health or medical conditions your child may have:*

If none, please write "none" or "N/A"

Please list any MEDICATIONS or MEDICAL DEVICES that your child(ren) will be bringing to camp; along with the purpose, dosage and if they need to take the medication at a specific time.*

If none, please write "none" or "N/A"

Additional registration notes for JA BizTown Staff:

Please list any additional information about your child(ren) that you feel is important for our staff to know.

Contact Information

Email Address:*

Confirm Email Address: *

Please provide an active email address as we will be sending reminders and updates via email.

Parent or Guardian*

First Name

Last Name

Parent or Guardian Phone (primary)*

Parent or Guardian Phone (alternate)*

Second Parent or Guardian

First Name

Last Name

Second Parent or Guardian Phone (primary)

Second Parent or Guardian Phone (alternate)

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Authorization of Who Can Pick Up Child From Camp

Please provide the names and phone numbers of those allowed to pick up your child from camp. If your emergency contacts are the only people authorized to pick up your child from camp, then you do not have to fill out this section.

Name of Person Authorized to Pick Up Child #1:

First Name

Last Name

Phone Number of Person Authorized to Pick Up Child #1:

Name of Person Authorized to Pick Up Child #2:

First Name

Last Name

Phone Number of Person Authorized to Pick Up Child #2:

Emergency Contact Information

Emergency Contact #1*

First Name

Last Name

Emergency Contact #1 Phone Number*

Emergency Contact #2*

First Name

Last Name

Emergency Contact #2 Phone Number *

Your child will not be released to anyone other than those listed as a parent, guardian, or emergency contact.

Release Validation

Emergency Contact Policy

By clicking on the agree button below you hereby authorize officials of Junior Achievement to 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 AGREE TO THE TERMS AND CONDITIONS STATED IN THE VALIDATION AND CONSENT FORM*

Agree

Date/Time

Photo / Video Policy

Unless stated otherwise in writing by the parent or guardian and received by Junior Achievement, your child may be photographed during JA BizTown Summer Camp for use on the JA website, JA promotional literature or any CD/DVD.

I AGREE TO THE TERMS AND CONDITIONS STATED IN THE VALIDATION AND CONSENT FORM*

Agree Disagree

Date/Time

Medical Release

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.

I AGREE TO THE TERMS AND CONDITIONS STATED IN THE VALIDATION AND CONSENT FORM*

Agree Disagree

Date/Time

PLEASE NOTE THAT WE NO LONGER OFFER AFTER-CARE

Camp Hours:

9am - 3pm

Extended Care:

8am-3pm

*If you have any questions on how to fill this portion of the registration form out, please contact Raena Rentsch at (317)-252-5900 ext. 0 or raena@jaindy.org.*

Camp Dates:

Please select one date ONLY

Number of Children Attending Regular Camp - Please enter "1" if your child is attending regular camp. If you have more than one child attending regular camp, "1" should still be entered in this box.

$240.00 Regular Camp

Number of Children Attending Extended Camp - Please enter "1" if your child is attending extended camp. If you have more than one child attending extended camp, "1" should still be entered in this box.

$265.00 Extended Camp

Number of Siblings Attending Regular Camp - Please enter "1" or "2" if your second/third children are attending regular camp.

$210.00 Regular Camp - Sibling

Number of Siblings Attending Extended Camp - Please enter "1" or "2" if your second/third children are attending extended camp.

$235.00 Extended Camp - Sibling

Total Cost $

Payment

Credit Card information is transmitted over a secure connection and stored in an encrypted database.

Pay by*

Credit Card

Credit card payments will be processed by PayPal. You will be redirected to a secure site for this transaction.

JA BizTown Summer Camp takes place at our JA BizTown location: 7435 N. Keystone Ave. Indianapolis, IN 46240

Junior Achievement of Central Indiana Federal Tax ID Number: 35-1003695.

Generously Sponsored By:

2024 JA BizTown Summer Camp Registration Form

Camper Information

Contact Information

Authorization of Who Can Pick Up Child From Camp

Emergency Contact Information

Release Validation

*PLEASE NOTE THAT WE NO LONGER OFFER AFTER-CARE*

Camp Hours:

9am - 3pm

Extended Care:

8am-3pm

Payment

PLEASE NOTE THAT WE NO LONGER OFFER AFTER-CARE