Camp Registration

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CJ Chabad Summer camp is dedicated to enriching the lives of children from diverse Jewish backgrounds and affiliations through a stimulating camping experience. CJCSC is part of the largest and fastest growing network of day camps, enjoying a reputation as a pioneer in Jewish camping, with innovative ideas and creative activities, to both provide enjoyment and inspire children to try new and exciting things!

The camp will be taking place on Monday June 26 through Friday July 14. Camp starts at 9AM and ends at 3PM. On Friday camp ends at 2PM.

There will be multiple trips, swimming every week, exciting shows and lots more fun planned!

The cost is $300 per week. Limited amount of scholarships are available.

For any questions or inquiries call Rabbi Dovi Levy 954-296-9971 or email [email protected].

Where did you hear about us?

Number of children being registered*

Full Name*

First Name Last Name

Hebrew name

Birth Date*

Month Day Year

Gender*

Grade entering*

Which school does your child attend?*

Sessions ($300 per session)*

Week 1Week 2Week 3

Pediatrician*

First Name Last Name

Phone Number*

Area Code Phone Number

Insurance*

My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise*

YesNo

Is your child allergic to any medications? If yes, please explain*

Is your child allergic to any foods? If yes, please explain*

Is your child up to date on all immunizations?

YesNo

Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain*

Please answer as accurately as possible - My child is:*

Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer.

Is your child adopted?

YesNo

Are there any social or other challenges we should be aware of?*

Full Name*

First Name Last Name

Hebrew name

Birth Date*

Month Day Year

Gender*

Grade entering*

Which school does your child attend?*

Sessions ($300 per session)*

Week 1Week 2Week 3

Pediatrician*

First Name Last Name

Phone Number*

Area Code Phone Number

Insurance*

My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise*

YesNo

Is your child allergic to any medications? If yes, please explain*

Is your child allergic to any foods? If yes, please explain*

Is your child up to date on all immunizations?

YesNo

Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain*

Please answer as accurately as possible - My child is:*

Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer.

Is your child adopted?

YesNo

Are there any social or other challenges we should be aware of?*

Full Name*

First Name Last Name

Hebrew name

Birth Date*

Month Day Year

Gender*

Grade entering*

Which school does your child attend?*

Sessions ($300 per session)*

Week 1Week 2Week 3

Pediatrician

First Name Last Name

Phone Number*

Area Code Phone Number

Insurance*

My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise*

YesNo

Is your child allergic to any medications? If yes, please explain*

Is your child allergic to any foods? If yes, please explain*

Is your child up to date on all immunizations?

YesNo

Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain*

Please answer as accurately as possible - My child is:*

Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer.

Is your child adopted?

YesNo

Are there any social or other challenges we should be aware of?*

If you have additional children, please contact us.

Mothers Full Name*

Mothers Phone Number*

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mothers E-mail* Primary email

Is the mother Jewish?*

YesNo

Fathers Full Name*

Fathers Phone Number*

Area Code Phone Number

Address Leave blank if same as above

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Fathers E-mail* Primary email

Marital Status*

MarriedSingleDivorcedSeparated

Are there any conversions in the family? If yes please explain.

YesNo

Child may be picked up from camp by:*

Name and Relationship

I would like to receive news and updates by email

Emergency Contact*

First Name Last Name

Phone Number*

Area Code Phone Number

Relationship*

I hereby give consent to the administration of CJ Chabad Summer Camp to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I understand that, when possible, every effort will be made to contact parent/guardian or emergency contact before CJCSC will undertake such a decision.

Signature of Parent or Guardian*

Total

$0.00

I would like to pay today:Full amount20% minimum: $0.00 $

Agreement*

I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid. I give CJ Chabad Summer Camp permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit.

General comments

Date & Time

Month Day Year

at Hour Minutes

PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of CJ Chabad Summer Camp (CJCSC) both on and off site, trips, transportation to and from trips etc., unless I advise you otherwise in writing.
Limited Guardianship Approval: I hereby consent that CJCSC's directors - Rabbi Dovi & Mrs. Pessi Levy be granted limited guardianship capabilities with regards to signing waivers on behalf of my child / children for trips specified in this year's camp schedule. (I do understand that I may still be asked to fill out waivers, as not all locations accept this consent)
PAYMENT AND CANCELLATION: Payment terms are a $50.00 non-refundable deposit per camper to accompany registration. The balance is due by June 9, and is non-refundable after that date.
DISMISSAL OF CAMPER: Parent fully understands and agrees that the Camp reserves the right to dismiss, in its sole discretion, any Camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the Camp or fellow campers or who violates camp rules and regulations. In the event of dismissal, tuition will be refunded on a prorated basis less the $50.00 registration deposit.
IMAGES, ETC.: Permission is hereby given to use in promoting the Camp and in other ventures directly relating to the Camp (i) digital, photographic and video images or likenesses of camper; audio of camper; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by camper or originating from Camp or from a Camp-related activity.
INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless CJ Chabad Summer Camp (CJCSC) and its officers, servants or assignees from any liability concerning our child’s involvement in CJCSC and further agree that the use of any premises during the CJCSC camp day is made at the risk of the registrant.
I have read and agree to all of the terms and conditions in this Application Form. I am including a non-refundable $50 registration deposit per camper along with submission of this form. I further agree to remit the full tuition and any other fees by June 9 as per the agreed timeline of my choice on this form.

Signature of Parent or Guardian*

Date & Time

Month Day Year

at Hour Minutes

Payment

Credit Card Other

Postal / Zip Code

Country

Camp Registration

1. Child/ren’s Information

Child 1

Medical Information Child 1:

Child 2

Medical Information Child 2:

Child 3

Medical Information Child 3:

2. Parents Information

3. Emergency Information

4. Payment Information

5. Terms and Conditions