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JA BizTown Summer Camp Registration
RequiredRequired Question(s)

Dear Parents,Use this questionaire to enroll your child in the JA BizTown Summer Camp program.  Camp will be held on July 29 - August 2, 2013 from 9:00AM - 3:30PM and is sponsored by Pride Mobility Products Corporation. 

 

All questions marked with a * are required to be answered.  A JA BizTown staff member will contact you via email to confirm your child's registration.

If you have questions, please contact the Junior Achievement office at 570-602-3600.

 

 

 

 

 

 

 
 
Required 1.

What is the camper's name?

 

50 characters left.
Required 2.

What is the camper's gender?

Male
Female
Required 3.

 What is the camper's age?  (Camp is open only to students entering fifth or sixth grade in the fall of 2013)


 

 

 
 

50 characters left.
Required 4.

Please select the grade the camper will enter in the fall of 2013.

 

 

 

 

 

 
Fifth Grade
Sixth Grade
Required 5.

Has your camper attended JA BizTown with their school?  Please note, previous experience is not required for summer camp attendance.

Yes
No
6.

Please enter the Mother or Guardian's First and Last Name:

 

50 characters left.
7.

Please enter the Father or Guardian's First and Last Name:

 

50 characters left.
Required 8.

Please enter the information indicated below for the Parent and/or Legal Guardian of the Camper.


Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 9.

Is the camper's address the same as the guardian's address indicated in question 8?

Yes
No
10.

If you answered "No" to Question 9, please enter the camper's home address below.

 

350 characters left.
Required 11.

Each camper will receive a t-shirt during camp week.  Please note the size desired:

Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Required 12.

Junior Achievement of Northeastern Pennsylvania, Inc. follows a strict pick-up policy.  Be sure to include all individuals to whom your child may be relased at pick-up time.  Your child will not be relased to any person whose name does not appear on this list.  NO EXCEPTIONS to this policy will be granted.

Below, please provide the name and telephone number of up to 3 people permitted to pick up your child.

 

1000 characters left.
Required 13.

In the event of an emergency, JA BizTown staff will first contact the parent or legal guardian of the camper.  If the parent/legal guardian cannot be reached, please provide the names and telephone numbers of at least two individuals that may be contacted.

 

1000 characters left.
Required 14.

Your child may be photographed during JA Summer Camp for use on the JA website, JA promotional literature or CD/DVD, and for the summer camp newspaper.  Please indicate whether or not your child may be photographed for such purposes.

Yes, my child may be included in photography that may be used to promote summer camp.
No, my child may not be included in photography that may be used to promote summer camp.
Required 15.

MEDICAL RELEASE

A completed medical release form must be returned prior to the first day of camp.  Please indicate how you wish to receive a copy of the form:

Email to email address noted above.
Regular mail sent to camper address noted above.
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