2026 JA BizTown Summer Camp Registration Form

Register your camper(s) for JA BizTown Summer Camp!
June 15 - 18, 2026 (Monday-Thursday)

9:00am drop off - 3:00pm pick up

JA Inspiration Center - 6600 44th Avenue, Suite 3, Moline, IL

JA BizTown Summer Camp, includes camp swag, daily snack, and Thursday lunch
Camper Information
Camper Name*

First NameMiddle NameLast Name
Gender*
Camper Age*
Grade 2026-2027 School Year*
Camper's School*
YesNo
YesNo
Please enter registration information for any additional campers below.
Include Camper: Name (First and Last), Gender, Age, Grade for 2023-2024 School Year, School
List any health or medical conditions that are relevant to your child's camp day:
Contact Information
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number(s): Please list phone number(s) in order of preference called
Phone Number 1*
Format: (000) 000-0000.
Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number 3
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number 4
Please enter a valid phone number.Format: (000) 000-0000.
Confirmations will be emailed to address provided*
example@example.com
Pick up and Emergency Contacts

For the safety of your child, we have a strict pick up system. Be sure to include all individuals to whom we are allowed to release your child at pick up time. Your child will not be released to any individual whose name does not appear on this list – NO EXCEPTIONS. List individuals, other than the parent/guardian, who can be reached in case of emergency and/or have the authority to pick you child up from camp.
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Who is allowed to pick up camper (Only individuals listed will be allowed to pick up campers. Must show ID for pick up. If there is a change to this list, please call JA Inspiration Center: 309.736.6816)?*
Doctor's Practice & Contact Information*
Additional comments (food allergies, etc.)
Yes!No thanks
Thank you for registering for JA BizTown Summer Camp!

After clicking submit, you will see a link to acknowledge and electronically sign required permission forms. These forms must be completed before your child can attend.

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Camp Registration

Please select the number of campers you are registering.

$200.00 Quantity
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Register your camper(s) for JA BizTown Summer Camp!

Camper Information

Contact Information

Pick up and Emergency Contacts

Thank you for registering for JA BizTown Summer Camp!

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