Friendship Circle End of Summer Camp 25

Drop off and pick up at Chabad - 74 Maple Ave. Cedarhurst

10:00 AM-3:00 PM

Cost: $50 a day

Your child will need:
Nut free Lunch
Change of clothing if needed (labeled)

Snack will be provided

Limited space available!

Name*

First NameLast Name

Primary Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Mothers Cell *

Please enter a valid phone number.Format: (000) 000-0000.

Fathers Cell *

Please enter a valid phone number.Format: (000) 000-0000.

In case of emergency and a parent can not be reached- Emergency Contact name and number :*

Does you child have any allergies? If yes, please detail.*

Does your child take any meds during camp hours? If yes, please detail.

Is your child toilet trained? Please explain your child's bathroom habits in detail.*

Please list any activities you would not like your child to participate in due to a limitation or medical condition that we should be aware of:

Please list any additional information our staff should know to ensure your child has a safe, and fun experience:

I hereby give permission to the Friendship Circle to transport my child to and from trips. (sign below)*

YesNo

Thursday, Aug 21 (White Post Farms)Monday, Aug 25 (Space Club)Wednesday, Aug 27 (Legoland)All of the above

CashCheckCredit Card Online

Camp ($50 a day)

USDPayment for Camp

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Medical & Emergency Release:My son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I hereby give my permission to the physician selected by the Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics may transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application. Liability Waiver I will not hold Friendship Circle liable for any accidents, injuries, damage or fatalities which may occur in transit to/from aforementioned events. I also waive all rights to sue Friendship Circle for any of the above mentioned incidents which may occur in transit. Sign your agreement below.*