TrajectUP presents -2018 Kids Summer Program @ CEJJES Institute

5 week program July 16th – August 17th

Register by 6/16/18 @ $250 per week- Limited Space

Purchase Here

Register Below

 















 

Contact Us @ 845-398-6001 Email: services@trajectup.com

Experienced professional staff

M-Thur (Drop off 8:45 am Pick up 4:00 pm) Fri 1/2 day Pick up 1:00 pm

Monday- Thursday *Bring your own lunch*

Age 6-13 years old

Fully insured

ELECTRONIC DEVICE FREE ZONE

Payment- Chase pay, Zelle, personal check and Paypal

CEJJES Institute – 5 Cooper Morris Drive, Pomona, NY 10970

 


 

Registration Form

Child

First Name

Last Name

Birth Date

Age (as of June 30, 2018)

School Name

Grade

Gender
MaleFemale



Parent/Guardian - Contact Information


Parent/Guardian #1

First Name

Last Name

Street Address

Town/City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email



Parent/Guardian #2

First Name

Last Name

Street Address

Town/City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email



Program Sessions:

Please indicate the registration sessions. (Please note that there are no partial sessions. Select as many dates as apply.)

Session 1 July 16-20Session 2 July 23-27Session 3 July 30-August 3Session 4 August 6-10Session 8 August 13-17


Registration Fee - $250 per week before 6/16, $350 per week beginning 6/17/18



Emergency Contact Information


Emergency Contact #1

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Relation to child



Emergency Contact #2

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Relation to child



Please list those people including in addition to parents/guardians who are permitted to pick up your child:

1.

2.

3.



Medical Release Information

Primary Physician

Address

Phone

Hospital Preference


Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
YesNo

If Yes, please explain


Is your child allergic to any type of food or medication?
YesNo

If Yes, please explain



The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.



I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

Parent’s/Guardian’s Initials



Please indicate how you heard about the TrajectUP Summer Program.

After School ProgramWebsiteFacebook AdSchoolWord of MouthFlyerOther

If by School or Other, please name



Terms of Agreement


Photo Release

I hereby give permission for my child to be photographed during the TrajectUP summer program. I understand the photos will be used to keep a journal of activities, to share during presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of TrajectUP, LLC.

Parent’s/Guardian’s Initials



All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders.

Parent/Guardian Signature

Date