Class/Activity Registration Form
Rosenthal JCC - Pleasantville Rosenthal JCC - Yorktown
600 Bear Ridge Road, Pleasantville, NY 10570 Crompond Road, Cortlandt Manor, NY 10567
(914) 741-0333 (914) 741-6150 Fax (914) 736-3076 (914) 736-3093 Fax
Are you a JCC Member? _Yes _ No Please check if this is a NEW address __
Family Last Name:__________________ Parents’ First Names:_______________________
(if minor)
Home Address:_________________________, ______________, ________ ___________
Street Address City / Town State Zip Code
Telephone: (____)_____-_________ (____)_____-_________ (____)_____-________
Home Work Cell
______________@_______.____ Emergency Contact:______________ (____)____-_____
Email Address
Class/Activity Time Day(s) Fee
______________________________ ____________________ ________ ______ $_________
Participant #1 Full Name
____/____/____ ____ ____ ____________________ ________ ______ $_________
Date of Birth Age Grade
____________ __ ASDC Member ____________________ ________ ______ $_________
School Name (if applicable)
______________________________ ____________________ ________ ______ $_________
Participant #2 Full Name
____/____/____ ____ ____ ____________________ ________ ______ $_________
Date of Birth Age Grade
____________ __ ASDC Member ____________________ ________ ______ $_________
School Name (if applicable)
______________________________ ____________________ ________ ______ $_________
Participant #3 Full Name
____/____/____ ____ ____ ____________________ ________ ______ $_________
Date of Birth Age Grade
____________ __ ASDC Member ____________________ ________ ______ $_________
School Name (if applicable)
METHOD OF PAYMENT Class/Activity Total….. $_________
__ Attached check #_________ made payable to the Rosenthal JCC
__ Please charge my:
__ MasterCard or __ Visa # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: _____/_____ Signature:___________________________________
Transportation from School (for school-aged children)
BYRAM HILLS: Coman Hill/Wampus pick-up for JCC
Check appropriate day(s) for pick-up: _ Mon _ Tues _ Wed _ Thurs _ Fri
Transportation is not guaranteed. Please call Nadeen at (914) 741-0333 x15 for confirmation.
If your child rides Bus 4C or 4W, check here __. If not, write in your child’s bus # here ____. In order for your child to ride bus 4C or 4W, you must present your child’s teacher and the bus driver with a note each time your child needs transportation to the JCC.
BRIARCLIFF, PLEASANTVILLE & MT. PLEASANT:
Please call Nadeen at (914) 741-0333 x15 for more information.
Safety Information If your child will be absent, arriving late, or picked up by someone other than a parent, parents are responsible for notifying Nadeen at the JCC by calling (914) 741-0333 x15. The JCC cannot accept responsibility unless a child is under the supervision of a JCC staff member. Supervision is available only at program locations, during program hours.
Class Refund Policy Refunds are given for classes that are cancelled due to lack of enrollment or over-subscribed ONLY. NO REFUNDS will be issued for membership fees, special events/programs or classes after the first session has been completed. There is a $10 processing fee for refunds.
Class Cancellations The JCC reserves the right to cancel any class, program or event due to an insufficient number of registrants.
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