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JCC on the Hudson Registration Form
371 South Broadway  Tarrytown, NY  10591
Tel:  914-366-7898
Fax:  914-366-7434

Family Name:  

Address

City State Zip

Phone

 

E-Mail Address: If you enter your email address in the blue "Email sign up" box you will be able to select your email preferences there and do not need to complete the information below.  All participants and subscribers receive a monthly general newsletter and reminders and updates on programs in your specified areas of interest.

Please send me updates on programs for:

Pre-Schoolers (Birth to 4 years)

Family Events

Grade Schoolers (5-12 years)

Teens (13-18 years)

Adults

Health & Fitness

Music and Performing Arts

Vacation and Summer Camps

 

If registering a child, please complete the following information:

Child's Name: Date of Birth:(MM/DD/YY)

Child's Name: Date of Birth:(MM/DD/YY)

 

Parent Contact Information

Parent Name:

Phone 1:

Phone 2:

Parent Name:

Phone 1:

Phone 2:

 

All program participants must list at least one emergency contact:

Emergency Contact Phone

Relationship to participant Cell/Beeper

 

Emergency Contact Phone

Relationship to participant Cell/Beeper

 

Class information:                             

Participant:  Name of Class: Day/Time: Fee*:

*Non-members are subject to a $10 insurance fee per participant per semester.

Payments cannot be accepted online.  Please call the JCC with your credit card information or print your form and enclose a check or the credit card information below.

 

Payment: Enclosed is my    ___check,    ___ Credit Card,    ___Debit Card

Please return your completed form with a check or credit card information to reserve your spot.

Card # ________________________________________ Expiration Date: _____________

 

Signature: _____________________________________ Security Code: ______________

                                                                                      as found on the back of your card

Make checks payable to JCC on the Hudson.