joey travolta’s asd summer inclusion film camp summer...

Engaging the mind, moving the body, enriching the soul, sharing smiles… _____________________________________________________________________________________________________________________________ _______________________

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Joey Travolta’s Short Film Camp - Summer 2017

Presented by: MarbleJam Kids

Location: ACADEMY OUR LADY OF MOUNT CARMEL - 10 COUNTY ROAD, TENAFLY, NJ 07670 Dates: July 10th – July 21st, 2017 Times: 10:00 am - 3:00 pm, Monday-Friday

CAMP REGISTRATION Fee: $75.00* – for ALL RETURNING CAMP APPLICANTS* (Returning Campers, or enrollees known to MJK with current Intake on file, need only to pay $75 Registration Fee)

CAMP INTAKE REGISTRATION Fee: $200.00** – for ALL NEW CAMP APPLICANTS** (For new clients unknown to MJK: This fee includes new applicant INTAKE fee $125.00 to be scheduled, and the above $75.00 Camp Registration fee)

2017 FILM CAMP TUITION: $2,000.00

Non Refundable Registration Fee: $75.00 * or $200.00**, per camper, due with completed application.

Applications: Must be COMPLETE and accompanied by $75.00* or $200.00** Registration Fee

Tuition Deposit: $500.00 of Camp Tuition, Due March 1st, 2017

Tuition Balance: Remaining Tuition Paid in Full, Due May 15th, 2017

*Registration Fee Waiver: Returning Campers, or current MJK enrollees, who pay tuition IN FULL by March 1st, will be forgiven the Registration Fee.

Requirements to attend this camp are as follows:

Individuals must be between the ages of 10-23

Enrollment open to typical peers and individuals with ASD or other special needs who function at a level that enables them to participate fully in this program.

Requirement level includes the following:

Must have good attending skills

Must demonstrate behavior that will not impede active and effective participation in camp

Verbal skills preferred

Must participate in the program in its entirety (see sample schedule)

Must be accompanied by qualified support staff (provided by the family) if support staff (1:1) is required at school.

Must be able to work in groups of 6 with one adult support person.

Space is limited. Please complete One Form per Applicant. Submit your child’s application today! Contact: MarbleJam Kids: Phone: 201-497-6512 Fax: 201-942-4450

Email: [email protected] Visit www.marblejamkids.org to download application.

RETURN 6 pages total, Including: 2017 Payment Form with Tuition Agreement Signature, PLUS 2017 Registration Form, PLUS 3

pages of 2017 Camp Application Questionnaire, PLUS Release Form

Mail to: JTSFC Administrator MarbleJam Kids Inc • 954 Kinderkamack Road, Suite 1 • River Edge, NJ 07661

mailto:[email protected]

http://www.marblejamkids.org/


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2017 FILM CAMP REGISTRATION FORM

MarbleJam Kids, Inc. Family Name: ________________________

Participant Registration Please complete ONE FORM per camper

_______________________________________________________________________________________________

PARTICIPANT’S NAME: (last) ________________________________ (first) _____________________________

Birth Date: ____________________ Age: ____________Male: ____ Female: _____ Special Needs Y____ N ____

School Attending _______________________________ Grade (Completed Spring 2017): _________

Teacher reference name: ______________________________ email: __________________________________

School Phone: ___________________________________

_______________________________________________________________________________________________

PARENT NAME 1: __________________________________________________________

Street: _______________________________ City: __________________ State: ______ Zip: _________

HOME PHONE #: _______________________________CELL PHONE #: __________________________________

EMAIL: (Please PRINT) _____________________________ @ ___________________________________________

PARENT NAME 2: __________________________________________________________

Street: _______________________________ City: __________________ State: ______ Zip: _________

HOME PHONE #: _______________________________CELL PHONE #: __________________________________

EMAIL: (Please PRINT) _____________________________ @ ___________________________________________

______My non-refundable registration fee of $75.00 or $200.00 is enclosed. Check # _________ Credit Card ______

_______________________________________________________________________________________________

MJKs Office Use:

Date Form Completed/Updated: _____________________

Registration Current: Y / N, Known Applicant: $75.00_______

New Applicant: $200.00_____________

Intake Scheduled Date: __________ Therapist: ____________ Intake Complete (Therapist Init):________

Comments: _________________________________________

MJKs Camp REG FORM 11/2015

Engaging the mind, moving the body, enriching the soul, sharing smiles…

MarbleJam Kids Inc. 954 Kinderkamack Road, Suite 1, River Edge, NJ 07661 P/ 201-497-6512 F/201-942-4450 www.marblejamkids.org

DAILY FILM CAMP PRODUCTION SCHEDULE (example)

Day 1: 10:00am: Check-in, Introduction, Opening Dancing, Group assignments 10:30am-12:00pm: Orientation to classroom groups (Divided according to age), Intro. to Acting Exercises, Film Terms 12:00pm-1:00pm Lunch 1:00pm-3:00pm Groups Short Film Development

Day 2:

10:00am-12:00pm Dancing, Acting Exercises, Film Terms 12:00pm-1:00pm Lunch 1:00pm-3:00pm Continue to Develop Script & Intro. to Lighting

Day 3:

10:00am -12:00pm Dancing, Acting Exercises, Film Terms 12:00pm-1:00pm Lunch 1:00pm – 3:00pm Introduction to Camera, Locking Script, Pitch Film Ideas to Director

Day 4:

10:00am -12:00pm Dancing, Acting Exercise Film Terms, Interviews with Director 12:00pm-1:00pm Lunch 1:00pm-3:00pm Casting Film, Script Budget Breakdown, Interviews, First Group Shoot begins

Day 5:

First Group Shoot Day 10:00am -12:00pm Dancing, Acting Exercise Film Terms, Interviews 12:00pm-1:00pm Lunch 1:00pm-3:00pm Casting Film, Script Budget Breakdown, Commercials, Set Design, Wardrobe, Interviews

Day 6: Second Group Shoot Begins 10:00am -12:00pm Dancing, Acting Exercises, Film Terms, Animation 12:00pm-1:00pm Lunch 1:00pm-3:00pm Third Group continue prep of films, Animation, First Group Editing

Day 7: Second Group Shoot Day 10:00am -12:00pm Dancing, Acting Exercises, Film Terms, Animation, Commercials 12:00pm-1:00pm Lunch 1:00pm-3:00pm Film Exploration, Third Group Shoot as able

Day 8: Third Group Shoot Day 10:00am -12:00pm Dancing, Acting Exercises, Film Terms, Animation 12:00pm-1:00pm Lunch 1:00pm-3:00pm Post production, Editing, commercials

Day 9: Third Group Shoot Day and Pick-ups 10:00am -12:00pm Dancing, Acting Exercises, Film Terms, Editing Third Group 12:00pm-1:00pm Lunch 1:00pm-3:00pm Post production, Editing Film, Animation

Day 10:

10:00am -12:00pm Dancing, Pick-ups, Acting Exercises, Film Exploration, Editing 12:00pm-1:00pm Lunch Pizza Party 1:00pm-3:00pm Screening of rough cut of films, On-camera Testimonials, Goodbyes


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Camp Tuition Schedule Requirements and Cancellation Policy

Please read carefully and sign signature page.

TUITION BALANCE DUE in full by MAY 15th, 2017

REGISTRATION FEE: A non-refundable registration fee of $75.00 or 200.00 per camper must accompany this application and be

received in order to hold your spot. First come first served to fill camper spots. (If your new camper child is not selected for

participation after a completed scheduled INTAKE, the fee will be refunded, less $100.00)

TUITION PAYMENT DEPOSIT: $500.00 due March 1st, 2017* for ALL accepted registrations

*Registration Fee Waiver- awarded to returning campers or current MJK enrollees paying TUITION IN FULL by March 1, 2017.

TUITION PAYMENT IN FULL: remaining tuition portion balance up to $1500.00 due MAY 15th, 2017. Must remit payment

directly to MarbleJam Kids. If you are expecting funding support from DDD, school district, or any other funding organization, fees

must be submitted to MarbleJam Kids by the above due dates. No exceptions. Families are required to explore, apply, and confirm

supplemental tuition funding on their own. In the event that MarbleJam Kids receives a tuition supplement directly from a funding

source, the money will be applied to your child's account and families will be promptly reimbursed the amount already paid.

CAMP TUITION ASSISTANCE APPLICATION: available April 15th, 2017 - assistance is determined by the outcome of

fundraising efforts. Maximum assistance per qualified applicant is $675.00. Children receiving NJ DDD camp funding are NOT

eligible for this program.

PAYMENT PLAN OPTION Please contact MarbleJam Kids directly to design a monthly payment plan option for camp tuition

IMMEDIATELY when submitting application. Please do not wait until payment due dates, or fee schedule cannot be altered and child

may have to forgo camper spot.

CANCELLATION POLICY: Cancellations with request for refund, less $75.00 or 200.00 registration fee, accepted in writing

before May 1st, 2015. All cancellations after May 1st are NOT eligible for refund. Tuition Payments will be considered a tax

deductible donation to the charity.

*TUITION TIMELINE

December 28th, 2016: Open enrollment begins for JTSFC 2017 – Registration Fee $75.00 or $200.00 due with

application.

March 1st, 2017*: $500.00 Tuition Deposit due

Plus $75.00 or 200.00 Registration Fee if not previously submitted.

*Registration Fee Waiver award with FULL TUITION PAYMENT submission

May 1st, 2017: Final date accepted for Cancellations with refund, less $75.00 or $200.00 registration fee.

May 15th, 2017: Final Tuition Balance Payments Due – remaining tuition portion balance up to $1500.00.

Payment totals at this time = $2,075.00 or $2,200.00 to MJKids

*Late Payments: Payment due dates noted above are firm. Payments received after above dates incur a $25.00 late

fee. Late fees apply to monthly payment plans as well.


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2017 Joey Travolta’s Short Film Camp APPLICATION (Please Complete One Form per Applicant)

Applicant Name: ______________________________________________ Age ______________

Date of Birth: ________________ Gender: Male Female

Home Address: ____________________________________________________

_____________________________________________________

Home Phone: __________________________________ Email: ________________________________

Mother/Guardian Name: _____________________________ Cell/Work Phone: ____________________

Father/Guardian Name: ______________________________ Cell/Work Phone: ____________________

T-Shirt Size (Circle): Adult Sizes: AS AM AL AXL

Youth Sizes: YL (14-16)

School Attending: ____________________________________Grade (Completed Spring 2017): _______

Mandatory: Please provide a school reference (e.g. teacher, principal, counselor, behaviorist):

Name of Reference: __________________________________________ Phone: ____________________

E-Mail: ___________________________________________________ Fax: ______________________

1. Has your child been diagnosed with a disability?

No: Peer Participant* ____ *(Peer participant: some questions may not apply.)

Yes: ____ please describe:

__________________________________________________________________________________

__________________________________________________________________________________

2. Describe your child’s interests and educational program: (Favorite activities, topics of interest, school

program, community program, in school and/or private therapies, etc.)

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

3. Does your child require a personal 1:1 aide at school? No Yes


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Camper Name ____________________________

4. Will his/her aide be attending this film camp? No Yes

Aide’s Name: ____________________________________________________

5. How does your child understand and interpret information? (Reads, uses written notes to assist with

auditory understanding, writes, uses picture schedule or written schedule, etc.)

__________________________________________________________________________________

__________________________________________________________________________________

6. How does your child communicate?

Conversational Phrases Single Words Points to Pictures ___ Aug. Comm. Device ____

7. What support helps your child communicate better? Verbal Prompts ___ Pictures ___ Written Text ___

Please describe:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

8. What is challenging for your child in a large group?

Attending Asking Questions Responding Compromising Contribution to a Group ___

Accepting Feedback Listening to Other’s Opinions Staying on Track with Task ___

Other; please describe:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

9. What challenging behaviors does your child experience? (Aggression towards classmates/adults, leaving

areas without permission, tantrums, fighting, verbal abuse, refusing to complete work, etc.)

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


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Camper Name ____________________________

10. Does your child? (Y/N) Ask Questions Stay on Topic of Other’s Interest Discuss Topics of Own

Interest Ask for More Information Make Comments About What Others Say ___

__________________________________________________________________________________

__________________________________________________________________________________

11. What type of behavioral support does your child receive?

__________________________________________________________________________________

12. Behavior Intervention Plan (Please Attach!) Behavior Services; please describe frequency of support, how

support is provided, if assistants are present/what they do:

__________________________________________________________________________________

__________________________________________________________________________________

13. In what situations is your child the most comfortable?

__________________________________________________________________________________

__________________________________________________________________________________

14. What situations make your child uncomfortable? (What happens, what makes the situation worse, what

helps most?)

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

15. What would you like to see your child get out of this experience?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

_________________________________

Name of Parent or Guardian

_________________________________ ______________________________

Signature of Parent or Guardian Date


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2017 Film Camp Release Form

CAMPER NAME: ____________________________________________

2017 Full Release and Indemnification Agreement Form

Joey Travolta’s Short Film Camp (mandatory for participation)

For and in consideration of my child’s, ______________________________(please print name), participation

in the Joey Travolta Short Film Camp (date) July 10th, 2017 through (date) July 21st 2017 and other valuable

consideration, the undersigned parent(s) or guardian(s) consent to their child participating in all activities

associated with the camp and release MarbleJam Kids Inc, Little Documentary Films, LLC, and Academy of

Our Lady of Mount Carmel, its members, employees, officers, and/or Board of Directors and all participating

volunteers and campers from any liability or claim resulting from any accident or injury sustained by my family

member during the camp activities. Further I/we agree to indemnify and assume all expenses, costs and fees,

and losses arising from said injury or accident to said family and to hold MarbleJam Kids Inc, Little

Documentary Films, LLC, and Academy of Our Lady of Mount Carmel, its members officers and/or Board of

Directors, employees and volunteers, consultants, and all campers free and harmless there from.

_____________________________ _____________


2017 Photograph/Video and Name Release Form

Joey Travolta’s Short Film Camp (mandatory for participation)

I give my permission to post photos/release video and use my child’s first name ____________________

(please print name) on the websites of MarbleJam Kids Inc., Full Inclusion Films, and other promotional

material for the Joey Travolta Short Film Camp as well as for research, teaching publications, film festivals,

media, and documentation.

_____________________________ _____________



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2017 Film Camp Payment Form Camper Name: ___________________________ I fully understand and agree to comply with MarbleJam Kids Camp Tuition Schedule Requirements for

Payment and Cancellation Policy, as outlined. Application will not be honored if this area is left unsigned.

Name: __________________________________________

Signature: ______________________________________ Date: ________________

Send Payments to: MarbleJam Kids

954 Kinderkamack Road, Suite 1

River Edge, NJ 07661

Attn: JTSFC Administrator

Please Accept My Check Payable to ‘MarbleJam Kids’: Amount $_________

My check # _________ is enclosed for: Registration _______ Deposit Payment in Full _______

Please accept my Credit Card Payment: Amount $_________

Name: ______________________________________________ (As it appears on card)

Billing Address: ______________________________________ Phone: ___________________

______________________________________

Visa ______ Master Card ______ AMEX ______ Discover ______ Amount: $________________

Card #_____________________________________________________ Exp. Date: ________________

V-Code ___________________ Signature: _____________________________________

Below to be completed by MJKs Staff:

Registration Fee: Date Received: _______________ Amount: $75.00 or 200.00 CC payment ________ Check # _______

Tuition Deposit: At least $500 Date Received: ________________ Amount: $______________ CC payment ________ Check # _______

Balance Due: ___________

Tuition Balance Payments: Date Received ________________ Amount: $____________ CC payment ________ Check # _______

Date Received ________________ Amount: $____________ CC payment ________ Check # _______



Paid in Full, Date Complete __________

joey travolta’s asd summer inclusion film camp summer...

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