Summer Camp Detailed Registration Form

Child information

Please fill out a separate form for each child

Child's Name

First Name Last Name

Birth Date

Month Day Year

School attending coming year

Grade going into coming year

ex. Nursery, Pre-K, Kindergarten, Primer

Gender

Male Female

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Information

Mother's Name

First Name Last Name

Mother's Occupation

Home Number

Cell Number

E-mail

example@example.com

Father's Name

First Name Last Name

Father's Occupation

Home Number

Cell Number

E-mail

Parents Marital Status

Are you a member of Congregation Israel?

Camp Options

A. 8 weeks, 5 full days	$2100
B. 8 weeks, 5 half days	$1400
C. 4 weeks, 5 full days	$1200
D. 4 weeks, 5 half days	$800

Hours are 8:30-3:30 M-F Half day is 8:30-12

Please choose one option from the above list

A B C D

TERMS OF ENROLLMENT

We reserve the right to add or cancel classes due to enrollment
All camp applications are due April 1
All accompanying forms must be submitted by the first day of camp (including medical records).

TERMS OF PAYMENT AGREEMENT

1. $50 non-refundable deposit ($150 after Feb 1st) is required for each child and must be submitted at time of application in order to reserve a spot. The fee will be applied to the child's tuition.

2. The balance of tuition is due by the first day of camp.

3.Payment plans are available. All arrangements must be confirmed in writing with the office and be completed prior to the first day of camp.

4. A late fee of $50 will be charged for all payments received after the first day of camp, unless previous arrangements have been made.

5. I have read and agree to the above terms.

You may pay the shul office by credit card or check payable to Congregation Israel of Springfield, NJ.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Clear

1. Name

1. Address

1. Phone

2. Name

2. Address

2. Phone

3. Name

3. Address

3. Phone

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Clear

Emergency Treatment Information

Authorization: I hereby give permission to the medical personnel selected by Congregation Israel to secure and administer treatment, including but not limited to X-rays, routine tests and hospitalization for the child named below.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Clear

Child's Name

Address

Parent 1

Best number to reach you at

Parent 2

Best number to reach you at

Emergency Contact's Name 1

First Name Last Name

Relationship

Phone Number

Emergency Contact's Name 2

First Name Last Name

Relationship

Phone Number

Pediatrician

Name Phone number

Dentist

Name Phone number

Insurance Carrier

Name Policy/Group Number

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is there anything else you would like us to know about your child?

The following email address and phone numbers should be used for Camp Kitanim communications (Email, Camp Kitanim WhatsApp group and text messaging)

Email

Phone number

CONSENT

1. At times we enjoy exploring our grounds. Please sign allowing your child permission to walk around the grounds of Congregation Israel.

2. Student Directory: I give my permission for my name, address, and email address to be put into the Camp Kitanim Directory.

Photo Permission

I give permission to congregation Israel, and all persons acting within its permission to use or publish photographic pictures of the above named student whether such pictures are still of video. Website & Social Media: I give permission for my child's picture to be used on the shul website and across its social media channels.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Clear

Camp Kitanim Registration 2022

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