Camp Chaverim Registration Form

1
Camper #1* This field is required.
First Name
Last Name
2
Camper #1* This field is required.
Male
Female
Other
3
Camper #1 Birth Date* This field is required.
Date
Month
Day
Year
4
Camper #1 Grade in the Fall* This field is required.
5
Choose which weeks Camper #1 will attend camp* This field is required.
Week 1: June 23 - 27
Week 2: June 30 - July 3 (closed July 4)
Week 3: July 7 - 11
Week 4: July 14 - 18
Week 5: July 21 - 25
Week 6: July 28 - August 1
Week 7: August 4 - 8
Week 8: August 11 - 15
6
Camper #1 T-Shirt Size* This field is required.
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
7
Add Camper #2?
YESNO
8
Camper #2* This field is required.
First Name
Last Name
9
Camper #2* This field is required.
Male
Female
Other
10
Camper #2 Birth Date* This field is required.
Date
Month
Day
Year
11
Camper #2 Grade in the Fall* This field is required.
12
Choose which weeks Camper #2 will attend camp* This field is required.
Week 1: June 23 - 27
Week 2: June 30 - July 3 (closed July 4)
Week 3: July 7 - 11
Week 4: July 14 - 18
Week 5: July 21 - 25
Week 6: July 28 - August 1
Week 7: August 4 - 8
Week 8: August 11 - 15
13
Camper #2 T-Shirt Size* This field is required.
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
14
Add Camper #3?
YESNO
15
Camper #3* This field is required.
First Name
Last Name
16
Camper #3* This field is required.
Male
Female
Other
17
Camper #3 Birth Date* This field is required.
Date
Month
Day
Year
18
Camper #3 Grade in the Fall* This field is required.
19
Choose which weeks Camper #3 will attend camp* This field is required.
Week 1: June 23 - 27
Week 2: June 30 - July 3 (closed July 4)
Week 3: July 7 - 11
Week 4: July 14 - 18
Week 5: July 21 - 25
Week 6: July 28 - August 1
Week 7: August 4 - 8
Week 8: August 11 - 15
20
Camper #3 T-Shirt Size* This field is required.
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
21
Add Camper #4?
YESNO
22
Camper #4* This field is required.
First Name
Last Name
23
Camper #4* This field is required.
Male
Female
Other
24
Camper #4 Birth Date* This field is required.
Date
Month
Day
Year
25
Camper #4 Grade in the Fall* This field is required.
26
Choose which weeks Camper #4 will attend camp* This field is required.
Week 1: June 23 - 27
Week 2: June 30 - July 3 (closed July 4)
Week 3: July 7 - 11
Week 4: July 14 - 18
Week 5: July 21 - 25
Week 6: July 28 - August 1
Week 7: August 4 - 8
Week 8: August 11 - 15
27
Camper #4 T-Shirt Size* This field is required.
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
28
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
29
Parent #1* This field is required.
First Name
Last Name
30
Parent #1 Email* This field is required.
example@example.com
31
Parent #1 Phone Number* This field is required.
Please enter a valid phone number.
32
Parent #1 Alternate Phone Number
Please enter a valid phone number.
33
Parent #2
First Name
Last Name
34
Parent #2 Email
example@example.com
35
Parent #2 Phone Number
Please enter a valid phone number.
36
Parent #2 Alternate Phone Number
Please enter a valid phone number.
37
Camper #1 Date of Last Physical* This field is required.
38
Camper #1 Most Recent Tetanus Immunization* This field is required.
39
Camper #1 Medications
40
Camper #1 allergies, special issues, other comments etc. that are helpful for us to know about:
Huge
Large
Normal
Small
Ok
Ok
41
Camper #2?
YESNO
42
Camper #2 Date of Last Physical* This field is required.
43
Camper #2 Most Recent Tetanus Immunization* This field is required.
44
Camper #2 Medications
45
Camper #2 allergies, special issues, other comments etc. that are helpful for us to know about:
Huge
Large
Normal
Small
Ok
Ok
46
Camper #3?
YESNO
47
Camper #3 Date of Last Physical* This field is required.
48
Camper #3 Most Recent Tetanus Immunization* This field is required.
49
Camper #3 Medications
50
Camper #3 allergies, special issues, other comments etc. that are helpful for us to know about:
Huge
Large
Normal
Small
Ok
Ok
51
Camper #4?
YESNO
52
Camper #4 Date of Last Physical* This field is required.
53
Camper #4 Most Recent Tetanus Immunization* This field is required.
54
Camper #4 Medications
55
Camper #4 allergies, special issues, other comments etc. that are helpful for us to know about:
Huge
Large
Normal
Small
Ok
Ok
56
Emergency Contact #1 (Other than Parents / Guardians)* This field is required.
First Name
Last Name
57
Emergency Contact #1 Cell Phone* This field is required.
Please enter a valid phone number.
58
Emergency Contact #1 Relationship to Child(ren)* This field is required.
59
Emergency Contact #2 (Other than Parents / Guardians)* This field is required.
First Name
Last Name
60
Emergency Contact #2 Cell Phone* This field is required.
Please enter a valid phone number.
61
Emergency Contact #2 Relationship to Child(ren)* This field is required.
62
Child(ren)'s Doctor* This field is required.Please list Doctor's Name, Practice, Phone Number
Huge
Large
Normal
Small
Ok
Ok
63
Transportation Permission* This field is required.My child(ren) has/have permission to be transported by bus/van provided by Camp Chaverim for off-campus activities. I understand that the children will be supervised and accompanied by camp staff at all times.
YESNO
64
Photograph / Video Permission* This field is required.Camp Chaverim has my permission to use photographs and/or video of my child(ren) in UJC newsletters and for publicity purposes.
YESNO
65
General Consent* This field is required.
66
Parent / Guardian Signature* This field is required.
Clear
Should be Empty: