Summer Camp 2024 Registration- New Family

Register online for the 2024 Summer Camp! Camp starts Tuesday, June 11th and runs until Friday, August 9th. We look forward to seeing you there!

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Summer Camp 2024 Student Health/Emergency Form

Step 1 of 4 - Student Information

Student Information
Name*
First Last
Birthdate*
Month
Day
Year
Grade in September 2024*
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Lives With*
- Both Parents
- Mother
- Father
- Other

Student Background*

In order to help us better meet your child's needs, please answer each of the following questions:

	Yes	No
Has this child ever repeated a grade?
Has this child ever been dismissed, suspended, or expelled?
Has this child ever been recommended for, or referred to, any Resource, ESL, or Special Education?
Has this child ever been diagnosed with any behavioral concerns (e.g., ADD, ADHD)?
Does this child have any physical limitations or handicaps?

Please briefly explain any "Yes" answers
Name of Child's Doctor:*
Physician's Phone #
Insurance:
Insurance ID #:
Student Health*
Please indicate the illnesses and diseases your child has or has had in the past:
Yes No
Allergy
Asthma
Diabetes
Epilepsy/Seizures
Fainting Spells
Vision Problem
Hearing Problem
Heart Condition
Migraine Headaches
Allergies (specify type)
Medications (specify any taken)
Significant Medical Problems
Mother/Guardian*
First Last
Home Address*
Same as previous

Street Address Address Line 2 City State ZIP Code
Email
Enter Email Confirm Email
Mobile Phone*
Home Phone
Work Phone
Father/Guardian
First Last
Home Address
Same as previous

Street Address Address Line 2 City State ZIP Code
Email
Enter Email Confirm Email
Mobile Phone
Home Phone
Work Phone
Custody Agreements
Custody*
Do you have any current custody agreements we should be aware of?
- Yes
- No
Description*
Please briefly describe the agreement. Any restrictions must be accompanied by a copy of the current court order.
Current Court Order
Please upload a copy of the current court order.
Max. file size: 32 MB.

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In the event that I am unable to pick up my child, he or she may be released to any of the persons listed below:
Name*
First Last
Relationship to Child*
Contact Information
Same as previous

Street Address City ZIP Code
Mobile Phone*
Other Phone
Name*
First Last
Relationship to Child*
Contact Information
Same as previous

Street Address City ZIP Code
Mobile Phone*
Other Phone
Name
First Last
Relationship to Child
Contact Information
Same as previous

Street Address City ZIP Code
Mobile Phone
Other Phone

Save and Continue Later

Authorization Agreement
Please read through the Admission Agreement and check the box below. Please note: Jubilee Christian School is known hereafter as "JCS."

JCS reserves the right to change or modify academic, administrative, and financial policies as necessary, while recognizing its obligation to give parents adequate notice of any changes.
Medical Authorization*
In the event of illness or injury, I do hereby authorize and consent to any x-ray, examination, anesthetic, medical, surgical, or dental diagnosis and/or treatment and hospital care are considered necessary in the reasonable judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing such medical or dental services. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required and is given to provide authority and power to render any care which the medical provider may reasonably deem advisable.

I further agree not to hold liable Jubilee Christian School, its officers, employees, board members, or agents for any such medical or health care services provided and to reimburse Jubilee Christian School for such medical or other health care expenses incurred in the child’s care.

This authorization is provided pursuant to Section 25.8 of the Civil Code of California.
- I have read, understand, and agree to the above
Parent/Legal Guardian Signature*

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Application Review
Please take a moment to review your Health/Emergency Form in full.
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Comments
This field is for validation purposes and should be left unchanged.

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First Name	Last Name	Birthdate	Prospective Grade

First Name	Last Name	Birthdate	Prospective Grade

Summer Camp 2024 Registration- New Family

Summer Camp 2024 Student Health/Emergency Form

Step 1 of 4 - Student Information

Student Information

Custody Agreements

In the event that I am unable to pick up my child, he or she may be released to any of the persons listed below:

Authorization Agreement

Application Review

Request Information

Schedule a Visit

	Yes	No
Allergy
Asthma
Diabetes
Epilepsy/Seizures
Fainting Spells
Vision Problem
Hearing Problem
Heart Condition
Migraine Headaches