2016-2017 Preschool Plus Application
Ages 2-5 year olds
Rosenbloom Jewish Community Center
3506 Gwynnbrook Avenue, Owings Mills, MD 21117 | 410.559.3554 | Fax 410.559.2473
FOR OFFICE USE ONLY
Date Recrd______________
Date Entrd______________
Memb #_________________
Cat_____________________
Amt of prog $____________
Proc in Acct by___________
Staff App___________
Entrd by____________
Sn 2017-MP_________
Exp Date___________
Dep $______________
Date_______________
Please return all three copies to program director. Please press hard.
Child’s Name __________________________________________________ Nickname ___________________________ Hebrew Name_________________________________
q Male q Female Date of Birth _________________________________________ Age as of September 1, 2016 Years____________________ Months_____________
Parents are q Single q Married/Domestic Partners q Separated q Divorced q Widowed q Check if you are a new family to the JCC ECE
Parent 1 Name_____________________________________________________________________________Home Phone____________________________________________
Address___________________________________________________________________________________Email___________________________________________________
Work Phone_______________________________________________________________________________Cell Phone______________________________________________
Parent 2 Name_____________________________________________________________________________Home Phone____________________________________________
Address___________________________________________________________________________________Email___________________________________________________
Work Phone_______________________________________________________________________________Cell Phone______________________________________________
Emergency Contact________________________________________________________________________Relationship_____________________________________________
Home Phone______________________________________Work Phone_____________________________________ Cell Phone_____________________________________
Names and ages of siblings___________________________________________________ Previous program/school attended (2015-2016)___________________________
Any Allergies______________________________________________________________________________ Any Medications_________________________________________
Names of siblings who attend other JCC Early Childhood programs_____________________________________________________________________________________
Monday-Friday, 7:00am-6:00pm | August 22, 2016 - June 16, 2017 | Summer Session: June 19 - August 11, 2017
Please check the desired program and circle the days and times. (Toilet training is required for children 4 years old.)
Children must be 2 by September 1, 2016
FEEDEPOSIT
q 5 days
$1,190
$476
q 4 days M T W Th F
$975
$390
q 3 days M T W Th F
$820
$356
q 2 days M T W Th F
$620
$248
Enrollment of 2 or more children qualifies for a 5% sibling discount.
All tuition charges will be charged on a monthly basis on the 20th of each month prior to the month’s enrollment; the JCC charges a $25 late fee for all payments 15 days past due. The monthly tuition charges, as noted above, are for the period August 22, 2016 to August 11, 2017.
Please select your payment option below (ACH or credit card).
q ACH Automatic Debit Authorization
q Checking q Savings (A check must be attached to this form in order to pay by ACH debit.)
Routing Number ___ ___ ___ ___ ___ ___ ___ ___ ___ Account Number ___ ___ ___ ___ ___ ___ ___ ___ ___
q Automatic Credit Card Authorization
q Visa q MasterCard q Discover q American Express | Credit Card #___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Exp Date _____ /_____ Amount Charged___________________________________________________
Credit Cardholder’s Name_________________________________________________________________ Phone________________
Cardholder’s Address_____________________________________________________________________
City/State/Zip____________________________________________________________________________
Cardholder’s Signature___________________________________________________________________
Cardholder agrees to pay the total amount according to the card issuer contact. Yes, I have read and understand all of the above.
I understand that the family must be JCC members at the time of enrollment and for the duration of the program. I understand that my deposit is
non-refundable and non-transferable, and is due in full at the time of registration. I understand the membership dues are non-refundable. I agree that my
child’s monthly tuition will be charged on the 20th of each month prior to the month’s enrollment. Payments will be charged to the credit card or ACH on file.
If my child leaves after the program starts, I will be responsible for that month’s tuition. I understand that any program changes I make after July 1, 2016, are
subject to a $60 service charge. All requests for program changes or withdrawals must be given in writing to the program director. Refunds will only be given
prior to the first day of the month attended. Any declined credit cards or ACH will be assessed a $25 return fee for reprocessing.
Photographs of my child taken during the program may be used for publicity purposes including but not limited to JCC websites, JCC Facebook pages, JCC
YouTube videos, JCC print and advertising materials. I give the JCC permission to release my telephone number and address for carpool and social interaction
purposes. I understand that my child’s placement will be determined by the program director.
Parent 1/Guardian Signature______________________________________________________________ Date_________________
Parent 2/Guardian Signature______________________________________________________________ Date_________________
Director’s Signature______________________________________________________________________ Date_________________
Jewish Community Center
of Greater Baltimore