January 2017
Dear SSECC Family,
Camp Saul Spielberg is just around the corner, and I hope your child/children will be joining
us for 9 weeks of fun in the sun!
This year, Camp Saul Spielberg will be traveling “Out of This World” – the theme of our
9-week camp program is Outer Space. We’ll kick off the summer by creating our very own
space station and rocket ships and we will learn about different planets and conduct planetspecific activities each week. Additionally, Monday through Thursday will include water play
and swim lessons for age appropriate campers. I can’t wait to blast off this summer and
hope that your children will join in the fun!
Additionally, this summer, we will be offering our parents a couple of incentives:
- Register by February 21st and receive an early bird discount!
- Refer a family and get a $50 check at the end of summer!
o To receive this referral bonus, the family you refer must write your name
on their family information sheet, register with their registration/activity
fee, pay their camp tuition, and attend camp!
In this packet, you will find one copy of all required registration forms. If you need more
copies, please visit the United Hebrew website and the Camp Saul Spielberg page. To
reserve your child’s space in camp, we will need all the completed registration forms and
the non-refundable registration and activity fee of $120 per child. If returned by February
21st, your registration and activity fee will be $100. The registration and activity fee
includes special guests (such as Joe Fingerhut, Beldin and Alice the Thinking Dog, The Magic
House, The St. Louis Zoo, and more!) plus pizza on Fridays!
We’re looking forward to a great summer!
Thank you!
Lauren Lourie
Director of Early Childhood Engagement
January 2017
To successfully register your child for camp, please use the
checklist below:
□
□
□
□
□
Program choice form
Family Information sheet
Health History form
Emergency Medical Consent form
Payment options sheet
Program Choice
Using the table below, please indicate by checking your child’s class choice and
circling whether your child will be MWF or full week.
Child’s Name:
Member
Non Member
Pricing
Pricing
9 weeks
9 weeks
CAMP DAY PROGRAM
(9 – 1)
M/W/F
Full Week
M/W/F
Full Week
Mayim (16 plus months)
$1000
$1600
$1150
$1750
M/W/F
Full Week
M/W/F
Full Week
Kochavim (Age 2 by July 31)
$1000
$1600
$1150
$1750
Full Week
Full Week
Etzim (Age 3 by July 31)
$1600
$1750
Full Week
Full Week
Keshet (Age 4 by July 31)
$1600
$1750
Full Week
Full Week
Shamayim (Age 5 by July 31)
$1600
$1750
CAMP DAY PROGRAM
Plus Extended Day
Full Week
Full Week
(9 – 3)
□
□
□
□
□
□
□
□
□
□
$2250
$2500
Kochavim (Age 2 by July 31)
$2250
$2500
Etzim (Age 3 by July 31)
$2250
$2500
$2250
$2500
$2250
$2500
Mayim (16 plus months)
Keshet (Age 4 by July 31)
Shamayim (Age 5 by July 31)
Session Choice
Camp can be divided into two sessions or you can choose the weeks you wish for your child to attend. If choosing
weeks, it’s a minimum of 5 weeks. Please check sessions or weeks below, note the pricing per session and week.
□ First session (June 5 through July 30)
June 5—
June 9
June 12—
June 16
June 19—
June 23
June 26—
June 30
Cost per session(week):
□
July 3—July
7
Second Session (July 3 through August 4)
July 10—
July 14
July 17—
July 21
July 24—
July 28
July 31—
August 4
Extra Options:
Member
Non Member
Early Care (7:30— 9:00)
$12 per morning
MWF (9-1)
$500 ($100)
$575 ($115)
Late Care (3:00— 6:00)
$10 per hour
Full Week (9-1)
$800 ($160)
$875 ($175)
Full Week (9-3)
$1,125 ($225) $1,250 ($250)
$6 per 1/2 hour
FAMILY INFORMATION
Child’s Name
□Male □Female
Birthdate
Age on August 1, 2017
Address
City, State, Zip Code
Home Phone
Member of United Hebrew?
□ Yes □ No □ Other:
Parent #1 Name
Work Phone
Cell Phone
Email Address
Parent #2 Name
Work Phone
Cell Phone
Email Address
NEW FAMILIES ONLY: How did you hear about us?
□Website
□Facebook
□Advertisement
If friend, please list their name:
□Friend
HEALTH HISTORY FORM
Child’s Name _____________________________________________
Birthdate ______________________________
Allergies:
Food ____________________________
Medication ____________________________
____________________________
____________________________
____________________________
____________________________
Other allergies or medication concerns (stings, hay fever, asthma, etc.)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Vaccinations:
__________
I have attached a copy of my child’s vaccinations.
__________
My child has his/her vaccination record on file at the SSECC that is less than 12
months old.
The health history is correct and complete to my knowledge, and the child stated has
permission to engage in all camp activities, except as noted. I hereby give permission to the
camp to provide car as they see necessary. I give permission to the camp to arrange
necessary related transportation for me/my child in the event of an emergency. In the
event I cannot be reached in an emergency, I hearby give permission for the physician,
selected by the camp, to secure and administer treatment, including hospitalization, for the
person named above.
Signature of parent/guardian __________________________________________ Date ________________________
Printed name __________________________________________
EMERGENCY MEDICAL CONSENT FORM
Child's Full Name___________________
Birthdate______________________
Home Phone _____________________
Parent/Guardian 1:
Parent/Guardian 2:
Name ___________________________
Name ___________________________
Business #____________________
Business # _______________________
Cell #____________________
Cell #____________________
Home #____________________
Home #____________________
Physician's Name ______________________
Phone #_________________________
Medication Allergies____________________________
Individuals who should be contacted in an emergency if parents can't be reached:
_______________________________ _________________ ________________________
Name
Relationship
Phone
_______________________________ _________________ ________________________
Name
Relationship
Phone
In case of a medical emergency, I give my permission for the school to contact my
child's physician if I cannot be reached. If it appears to be necessary, I authorize a
school representative to call 911 or take my child to the nearest hospital.
Hospital of Choice
___________________________________
Parent's Signature
_____________________________
Date
PAYMENT OPTIONS
REGISTRATION and ACTIVITY FEE PAYMENT OPTIONS
Registration and activity fee of $120 ($100 prior to February 21, 2017)
□ Enclosed is a check for our registration fee. Check #
□ Charge registration fee to credit card. (A 3% fee will be added to all
charges to cover the cost of fees incurred)
Registration fee for $
will be charged upon receipt.
CAMP TUITION PAYMENT OPTIONS:
*If choosing to pay by credit card, you will incur an additional 3% in credit card fees*
□ Charge full amount to credit card listed below on April 25. $
□ Pay in 2 monthly installments (April 25 and May 23). Monthly payment: $
□ I will write a check for the full amount due on April 25. Please send
statement.
□ I will write 2 checks for the full amount due on April 25 and May 23.
Please
send statements for both amounts.
Credit Card Authorization (I authorize United Hebrew Congregation to initiate
charges as shown above, on the credit card indicated. This authority will remain in effect
until our camp account is paid in full. I understand that the 3% in fees will be charged as
well)
Visa
MasterCard
Discover
AMEX
Card Number
Print Name as it Appears on Card
Expiration Date
Authorization Signature
Security Code
Address, City, State, ZIP