Winter Camp 2022 Registration form

For any questions or more info, contact Rabbi Mendel Stiefel.

972-625-1525 #105 or email [email protected]

Fathers Name*

First Name Last Name

Mothers Name*

First Name Last Name

Parents' Statues*

Married Divorced Widowed Seperated Other

E-mail*

Address*

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

Phone Number*

Area Code Phone Number

Additional phone Number

Area Code Phone Number

Child #1 - Name*

First Name Last Name

Child #1 - Birth Date*

Month Day Year

Please pick the dates you would like to register your child for.

Either pick the entire week or individual days.

Child #1 - Dates* Early bird till December 1. Please pick the entire week or the individual days you would like to register for. *Wednesday is $85 due to the cost of the trip

Entire week Monday Tuesday Wednesday Thursday

History of Disease past / present. Record any medical issues suffered*

Do you have any current health problems?*

Yes No

Are you now under medical care or taking any medication?*

Yes No

Do your child have allergies?*

Yes No

If you answered yes to any of the above 3 questions, please explain

Child #2 - Name

First Name Last Name

Child #2 - Birth Date

Month Day Year

Child #2 - Dates Early bird till December 1. Please pick the entire week or the individual days you would like to register for. *Wednesday is $85 due to the cost of the trip

Entire week Monday Tuesday Wednesday Thursday

History of Disease past / present. Record any medical issues suffered

Do you have any current health problems?

Yes No

Do you have any current health problems?

Yes No

Do your child have allergies?

Yes No

If you answered yes to any of the above 3 questions, please explain

To the best of my knowledge, history is correct and complete; I know of no reason to restrict applicant's activity, and give my permission for participation in all activities, except as specifically noted herein. In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. I also understand that if my child has a medical condition that may require medication, inhaler, EpiPen or the like, that I MUST submit these along with any necessary form signed by my doctor prior to or on the first day of camp. The above includes an Allergy Action Plan for any type of Allergy. Phone orders from parents requesting the camp administration to administer any medication including 'over the counter' will not be accepted.

I have read and agreed to the information in this form*

Yes No

Additional Donation Optional. Thank you!

$

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Refund policy

We are unable to offer any refunds for illness of a camper that prevents him/her from attending our program.

I give my child/ren permission to attend all camp trips*

Yes No

I give permission for my child/ren to be in camp photos and allow the photos to be used publicly*

Yes No

Chabad Center of Northwest NJ Waiver of Liability Agreement I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Chabad Center of Northwest NJ and individually, its officers, employees, and agents from liability from any and all claims, lawsuits and liability, including the negligence of 'Chabad Center NWNJ' its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation of my child in Gan Israel Winter Camp which is a division of the The Chabad Center of NWNJ and is being conducted on ts property. The above shall includes all matters related to the COVID-19 (coronavirus) pandemic. Acknowledgement of Understanding: I have read this waiver of liability, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

I have read and agreed to the information in this form*

Yes No

Signature and date*

$50 $75 $100

Winter Camp 2022 Registration form

CGI Winter Camp 2022 Registration form

Family information

Camper Information

Child #2 - Camper Information

Health Form Waiver

Payment form

Waiver

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