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Summer Camp Registration Request 2019: Teens

This Camp Form is only a request for registration.  If you have multiple children, you must submit one form per child. Requests will be handled in the order they are received.  Your credit card will not be immediately charged, even after checkout. Your purchase will be manually charged at a later date based on your selected payment method. This form cannot be used if you require financial assistance.  If you require financial assistance, please contact Doreen Sparks at 704-944-6728.

Are you a Levine JCC member?

Camper's First Name
Camper's Last Name
Date of Birth (MM/DD/YYYY)
Grade Aug 2019
Address 2
Sibling(s) Enrolled in Camp

Parent Contact Information:
Mother's Name
Work Phone
Cell Phone
Father's Name
Work Phone
Cell Phone

Emergency Contacts (other than parent): 
Full Name
Relation to Camper
Home Phone
Buisness Phone
Full Name 2
Relation to Camper 2
Home Phone 2
Business Phone 2


Throughout this year, families have asked for an opportunity to make a tax-deductible gift to The Mindy E. Levine Day Camp. Such gifts of kindness and generosity are deeply appreciated as an expression of Tzedakah - a truly significant Jewish value.

Your tax-deductible gift is especially appreciated and will be reflected on your confirmation-of-registration letter mailed to you in the coming weeks.

I would like to make a voluntary contribution to the Mindy E. Levine Day Camp Fund.
 $18  $36  $100  Other
Other Amount: $


  1. $300 non-refundable deposit per camper is required at the time of registration.
  2. All camp fees are to be paid in full following the terms of the Payment Authorization Form, which must accompany the application.
  3. Permission is granted for photographs to be taken of my child to be used for future publicity.
  4. Permission is granted for my child to take part in all camp activities including trips and extended days.
  5. Permission is granted to the Camp Mindy staff to authorize emergency medical treatment for my child should the need arise.
  6. Permission is granted to apply sunscreen on my child as needed.
  7. There will be a $75 per week Change Fee assessed to any change in original enrollment, except for those which will extend the camper’s stay.
  8. All camp forms must be turned in by May 5, 2019. Campers will not be allowed to attend camp without completed medical forms.
  9. The Administrative Staff should be made aware of any special needs or limitations of individual campers.
  10. The Administrative Staff reserves the right to cancel any camper’s enrollment or dismiss a camper whose medical condition, conduct, influence, or behavior is deemed unsatisfactory to the best interests of the camp.
  11. Groups will be formed by the number of weeks campers attend camp, however, there may be exceptions and the administrative staff will have final say on placement decisions.
 I hereby register my child for the 2019 Camp at the Levine Jewish Community Center. I understand and agree to all terms and conditions in this and all other documents pertaining to rules and policies of the Levine Jewish Community Camp.

Gesher Teen Traditional Camp

* No camp July 4

Session 1: June 17 - June 28 (2 Weeks)
 Member: $830  Non-member: $930  
Session 2: July 1 - July 12 (2 Weeks) *
 Member: $805  Non-member: $905  
Session 3: July 15 - July 26 (2 Weeks)
 Member: $830  Non-member: $930  
Session 4: July 29 - August 2 (1 week)
 Member: $445  Non-member: $495  

Production Camps

* No camp July 4

Disney's My Son Pinocchio Jr. (Open to Grades 2-8) M-F: 9am-4pm June 17-July 13 (4 weeks) *
 Member: $1450  Non-member: $1650
Disney’s Sleepy Beauty KIDS (Open to Grades 2-8) M-F: 9am-4pm July 15-August 3 (3 weeks)
 Member: $1100  Non-member: $1250
Disney’s My Son Pinocchio PLUS Sleeping Beauty (Open to Grades 2-8) M-F: 9am-4pm June 17-August 3 (7 weeks) *
 Member: $2325  Non-member: $2675

Teen Camps

* No camp July 4

New! A Taste of Teen Camp (Rising 4th, 5th & 6th Grade) August 19-23
 Member: $400  Non-member: $450
ATHENA’S PATH LEADERSHIP CAMP FOR GIRLS (Rising 6th, 7th & 8th Grade Girls) August 5-9
 Member: $310  Non-member: $335
ATHENA’S PATH LEADERSHIP CAMP FOR GIRLS II (Rising 6th, 7th & 8th Grade Girls) August 5-9
 Member: $310  Non-member: $335
Counselor in Training Program (CIT) - (Rising 9th graders) June 17-July 12 (4 weeks) * • M-F, 9am-4pm
 Member: $830  Non-member: $1030
Leaders in Training Program (LIT) - (Rising 10th graders), July 15-August 2 (3 weeks) • M-F, 9am-4pm
 Member: $625  Non-member: $775

Payment Options

Total Amount Due $
Please contact me regarding an extended payment plan.
Please contact me regarding financial assistance.
Payment Options
 Pay now in full
 Payment plan

Note: $300 Deposit required at time of registration if not paying in full. Please deduct the $300 deposit from your total when making your payment plan.

May 5th payment $
June 5th payment $

I authorize the Sandra and Leon Levine Jewish Community Center (Levine JCC) to initiate debit entries on my credit (or debit) card account in the amount and by the method indicated above.

I authorize the credit card institution to debit my account, for the amount indicated, on the 5th day of each month until my camp fees are paid in full. I understand that the Levine JCC will notify me, in advance, of any change in the monthly fee charged to my account due to any change in fees for new services added by my consent.

 Credit Card Authorization
Card Type
Name on Card
Card Number
Expiration Date
Total: $0.00
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