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Summer Day Camp 2023

Please complete the application below in full. An asterisk (*) marks the required questions.

  • If you have more than one child you would like to enroll in the Summer Day Camp, you may use this form to apply for up to three children. Please be sure to fully complete all information. If you need to apply for a fourth child, please complete this form again.
  • If you have any questions regarding James River's Summer Day Camp, please contact Katrina Phillips ([email protected]).
The 1st child's gender is ...*
Answer Required
This 1st child's age is ... *
Answer Required
The 2nd child's gender is ...
Answer Required
The 2nd child's age is ...
Answer Required
The 3rd child's gender is ...
Answer Required
The 3rd child's age is ...
Answer Required

Parent/Guardian Information

1st Parent's/Guardian's Title*
Answer Required
2nd Parent's/Guardian's Title
Answer Required

Emergency Contacts

Other than the parents/guardians, list two persons at two separate addresses whom we should contact if we are unable to reach either parent listed above. These two persons must live LOCALLY.

Agreements, Swimming Permission & information

The undersigned parent(s)/guardian(s) give authorization for this child/these children to participate in field trips which leave the school campus.*
Answer Required
Summer Day Camp personnel will notify a parent/guardian whenever their child becomes ill, and the parent(s)/guardian(s) agree(s) to pick up the child as soon as possible.*
Answer Required
The undersigned parent(s)/guardian(s) authorize the JRDS Summer Camp/James River Day School personnel to obtain immediate medical care for their child/children if any emergency occurs in the event a parent/guardian cannot be located immediately.*
Answer Required
The parent(s)/guardian(s) will inform JRDS Summer Camp personnel within 24 hours or the next business day after this child (these children) or any other member of the family develop(s) any reportable, communicable disease as defined by the Virginia Dept. of Health, except for life-threatening diseases, which must be reported immediately.*
Answer Required
The undersigned parent(s) give permission for the above-named child/children to swim at a local pool.*
Answer Required
My child/children is/are (check all that apply):*
Answer Required

Electronic Signature(s)

Only one parent's/guardian's signature below is required, though having both signatures is preferred.

My electronic signature below affirms that all of the information contained in this form is correct, complete, and honestly presented. I understand that withholding or misrepresenting information in this packet may jeopardize my child's JRDS Summer Day Camp enrollment.*
Answer Required

Required Payments

Price: $25.00
Price: $225.00
Only 5 left in stock
Please indicate below which weeks your child will be enrolled in James River's Summer Day Camp.*
Either choose the full nine-week option OR as many of the numbered weeks (1-9) as your family needs.
Answer Required

The Children's Center Director, Katrina Phillips, will be in touch as soon as possible.

Thank you for your interest in The Children's Center at James River Day School.


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