Registration - Chabad of Danville & S. Ramon

Camper Information

Camper 1

Name*

First NameLast Name

Hebrew Name (if known)

Date of Birth*

MonthDayYear

Age

Gender

Camper 2

Name

First NameLast Name

Hebrew Name (if known)

Date of Birth

MonthDayYear

Age

Gender

Camper 3

Name

First NameLast Name

Hebrew Name (if known)

Date of Birth

MonthDayYear

Age

Gender

Family

Home Address*

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

Home Phone

Area CodePhone Number

Parent Information

Father's Name

First NameLast Name

Hebrew Name (if known)

Cell Phone

Area CodePhone Number

E-mail

Mother's Name

First NameLast Name

Hebrew Name (if known)

Cell Phone

Area CodePhone Number

E-mail

Medical and Special Needs Details

Is your child taking permanent medications?*

NoYes

If Yes, please specify:

Any known allergies (incl. reactions to medications) and any present medical conditions?

NoYes

If Yes, please specify:

If Other, please specify:

Does your child require the use of an epi-pen?

Is your child gluten-free?

NoYes

If Yes, please list 2 snacks your child will enjoy:

Emergency Information

Emergency Contact

First NameLast Name

Relationship to child

Cell Phone

Area CodePhone Number

Doctor's Name

First NameLast Name

Doctor's Telephone

Area CodePhone Number

Other person authorized to pick up child

Name

First NameLast Name

Relationship to child

Cell Phone

Area CodePhone Number

Address

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

Accident, Field Trip and Privacy Declaration

Accident

As the parent(s) or legal guardian of my/our child, I/we authorize any adult acting on behalf of Danville Hebrew School to hospitalize or secure treatment for my child; I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Danville Hebrew personnel will try, but are not required to communicate with me prior to such treatment.

Agreement

I Agree

Date

MonthDayYear

Trips & Outings

I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Danville Hebrew.

Agreement

I Agree

Date

MonthDayYear

Privacy

I hereby give permission for my child’s photographs/videos to be used for educational or promotional purposes, which include but are not limited to, brochures, Danville Hebrew website and Danville Hebrew social media. I understand that I can withdraw my consent at any time.

Agreement

I Agree

Date

MonthDayYear

Billing

Billing covers all electives, activities, trips, snacks & drinks.

Pricing

1st week attending $395

2nd week attending $385

3rd week attending $375

Danville Hebrew offers the following discounts, if you are in need of steeper discounts, please email [email protected]

NEW! Multi Week Discount: $10 discount off each additional week!

Second Child Discount:$15 off per week of second child

Additional Child Discount: $30 off per week of 3rd or more child/ren

Please make all checks payable to Chabad of Danville & S. Ramon and mail to Chabad of Danville & S. Ramon P.O Box 3541 Danville CA 94526.

Child 1 Attending:*

Child 2 Attending:

Child 3 Attending:

My child/children will be attending:*Please select all that apply:

Week 1: July 11-15Week 2: July 18-22Week 3: July 25-29

I would like to make a tax deductible contribution to the Camp Scholarship Fund in the amount of

Total:Enter total for selected weeks- including discounts

A limited number of scholarships are available upon request; no child will be turned away for lack of funds.

Payment

Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

Notes

E-mail

I would like to receive news and updates by email

Summer Camp Enrollment Form 2022