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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]).

1st child's full name (first middle last)*

Answer Required

What is the 1st child's nickname/preferred name?*

Answer Required

The 1st child's gender is ...*

Answer Required

This 1st child's age is ... *

Answer Required

This 1st child's date of birth is ...*

Answer Required

Does this 1st child have allergies or food intolerances? If so, please describe. If not, write "none."*

Answer Required

For the 1st child, please describe any emergency action that should be taken for allergies listed above. If there are none, write "none."*

Answer Required

For the 1st child, please list and describe any special medical or chronic physical conditions. If there are none, write "none."*

Answer Required

For the 1st child, please list any over-the-counter (OTC) or prescription medications this child takes on a regular basis.*

List the medication name, dosage, frequency, and prescriber or OTC for each medication.

Answer Required

Where does the 1st child attend school?*

Answer Required

2nd child's full name (first middle last)

Answer Required

What is the 2nd child's nickname/preferred name?

Answer Required

The 2nd child's gender is ...

Answer Required

The 2nd child's age is ...

Answer Required

The 2nd child's date of birth is ...

Answer Required

Does this 2nd child have allergies or food intolerances? If so, please describe. If not, write "none."

Answer Required

For the 2nd child, please describe any emergency action that should be taken for allergies listed above. If there are none, write "none."

Answer Required

For the 2nd child, please list and describe any special medical or chronic physical conditions. If there are none, write "none."

Answer Required

For the 2nd child, please list any over-the-counter (OTC) or prescription medications this child takes on a regular basis.

List the medication name, dosage, frequency, and prescriber or OTC for each medication.

Answer Required

Where does the 2nd child attend school?

Answer Required

3rd child's full name (first middle last)

Answer Required

What is the 3rd child's nickname/preferred name?

Answer Required

The 3rd child's gender is ...

Answer Required

The 3rd child's age is ...

Answer Required

This 3rd child's date of birth is ...

Answer Required

Does this 3rd child have allergies or food intolerances? If so, please describe. If not, write "none."

Answer Required

For the 3rd child, please describe any emergency action that should be taken for allergies listed above. If there are none, write "none."

Answer Required

For the 3rd child, please list and describe any special medical or chronic physical conditions. If there are none, write "none."

Answer Required

For the 3rd child, please list any over-the-counter (OTC) or prescription medications this child takes on a regular basis.

List the medication name, dosage, frequency, and prescriber or OTC for each medication.

Answer Required

Where does the 3rd child attend school?

Answer Required

Parent/Guardian Information

1st Parent's/Guardian's Title*

Answer Required

1st Parent's/Guardian's Preferred Name/First Name*

Answer Required

1st Parent's/Guardian's Last Name*

Answer Required

1st Parent's/Guardian's Email*

Answer Required

1st Parent's/Guardian's Cell Phone*

Enter the ten-digit phone number without dashes or parentheses.

Number Required

1st Parent's/Guardian's Home Phone

Number Required

1st Parent's/Guardian's Place of Work*

Write N/A if this is not applicable to the 1st parent/guardian.

Answer Required

1st Parent's/Guardian's Work Phone

Enter the ten-digit phone number without dashes or parentheses.

Number Required

1st Parent's/Guardian's Home Address*

Answer Required

1st Parent's/Guardian's City, State, Zip Code*

Answer Required

2nd Parent's/Guardian's Title

Answer Required

2nd Parent's/Guardian's Preferred Name/First Name

Answer Required

2nd Parent's/Guardian's Last Name

Answer Required

2nd Parent's/Guardian's Email

Answer Required

2nd Parent's/Guardian's Cell Phone

Enter the ten-digit phone number without dashes or parentheses.

Number Required

2nd Parent's/Guardian's Home Phone

Enter the ten-digit phone number without dashes or parentheses.

Number Required

2nd Parent's/Guardian's Home Address

Answer Required

2nd Parent's/Guardian's City, State, and Zip Code

Answer Required

2nd Parent/s/Guardian's Place of Work

Answer Required

2nd Parent's/Guardian's Work Phone

Enter the ten-digit phone number without dashes or parentheses.

Number Required

The person(s) or Agency having legal custody of this child are?

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.

1st Emergency Contact's First/Preferred Name and Last Name*

Answer Required

1st Emergency Contact's Cell Phone or Best Daytime #*

Enter the ten-digit phone number without dashes or parentheses.

Number Required

1st Emergency Contact's Email Address*

Answer Required

1st Emergency Contact's Address (street address plus city, state, and zip)*

Answer Required

2nd Emergency Contact's First/Preferred Name and Last Name*

Answer Required

2nd Emergency Contact's Cell Phone or Best Daytime #*

Enter the ten-digit phone number without dashes or parentheses.

Number Required

2nd Emergency Contact's Email Address*

Answer Required

2nd Emergency Contact's Address (street address plus city, state, and zip)*

Answer Required

Are there other persons who will be regularly picking up your child or who are authorized to pick up your child on an occasional basis?*

List each person's name, best daytime number, relationship to this child, and whether this is will be a regular or occasional pick-up.

Answer Required

List any persons who are barred from picking up your child. (A copy of the divorce decree or restraining order mandating this is required.)

Answer Required

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

Yes

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

Yes

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

Yes

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

Yes

The undersigned parent(s) give permission for the above-named child/children to swim at a local pool.*

Answer Required

Yes

My child/children is/are (check all that apply):*

Answer Required

a non-swimmer.

able to swim is shallow water.

able to swim in water above their shoulders.

completely at home in the water and able to swim in water above their head.

Please describe your child's/children's swimming ability and level of swimming experience below (please do this for every child you are registering).*

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

Yes, and I/we acknowledge that the electronic signature(s) below and their related fields are treated by James River Day School as a physical handwritten signature on a paper form.

1st Parent's/Guardian's Electronic Signature*

1st Parent/Guardian, please type your full name below.

Answer Required

Date of the 1st parent's/guardian's signature above*

Answer Required

2nd Parent's/Guardian's Electronic Signature

1st Parent/Guardian, please type your full name below.

Answer Required

Date of the 2nd parent's/guardian's signature above

Answer Required

Required Payments

Non-refundable Application Fee*

Price: $25.00

Non-refundable, prepayment of $225 to secure my child's spot. This $225 will be applied to the bill for Summer Day Camp for the above-named child.*

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

I want to enroll my child(ren) in the Summer Day Camp for all nine weeks.

Enroll my child(ren) for Week 1 (June 12-16).

Enroll my child(ren) for Week 2 (June 19-23).

Enroll my child(ren) for Week 3 (June 26-30).

Enroll my child(ren) for Week 4 (July 5-7).

Enroll my child(ren) for Week 5 (July 10-14).

Enroll my child(ren) for Week 6 (July 17-21).

Enroll my child(ren) for Week 7 (July 24-28).

Enroll my child(ren) for Week 8 (July 31-August 4).

Enroll my child(ren) for Week 9 (August 7-11).

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.

Please enter your email below, so we may send you a confirmation of all the information you entered above.

Confirmation Email

Confirmation Email *

Email Required

Order Summary

Total

Total must be at least $1.00 or set total to zero

0.00

Name *

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Credit or debit card

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