Summer Camp 2024 Detailed Registration Form

Camp Kitanim Registration 2024

June 25-Aug 16
Child information

Please fill out a separate form for each child
Child's Name

First NameLast Name
Birth Date

MonthDayYear
School attending coming year
Grade going into coming year
ex. Nursery, Pre-K, Kindergarten, Primer
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Mother's Name

First NameLast Name
Mother's Occupation
Home Number
Cell Number
E-mail
example@example.com
Father's Name

First NameLast 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, full days	$2400
B. 8 weeks, half days	$1650
C. 4 weeks, full days-first session	$1500
D. 4 weeks, half days-first session	$1000
E. 4 weeks, full days-second session	$1500
F. 4 weeks, half days-second session	$1000

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

Sessions

1- June 25- July 19

2- July 22- August 16

Please choose one option from the above list

ABCDEF
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
PICK UP FORM

The following people have my permission to pick up my child(ren):
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 NameLast Name
Relationship
Phone Number
Emergency Contact's Name 2

First NameLast Name
Relationship
Phone Number
Pediatrician

NamePhone number
Dentist

NamePhone number
Insurance Carrier

NamePolicy/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
Should be Empty:

Camp Kitanim Registration 2024

PICK UP FORM