Camp Registration - Eastside Torah Center

UPDATE: All camp submissions sent today will be on the waiting list.

Teen Information

First Name (shown on ID)*

Last Name*

Gender*

Nickname*

Date of Birth*

Current Grade*

Weeks Attending: Week 1 Week 2 Week 3

Teen Cell Phone*

Teen Email only

Address*

City*

Zip*

Height*

Weight*

On a scale from 1 to 10, how adventurous are you?
1 2 3 4 5 6 7 8 9 10

Parent Information

Address*

City*

Zip*

Marital Status*

Any adoptions?*

How did you hear about us*

Father's Name

First*

Last*

Cell*

Email Address*

Is Father Jewish

Mother's Name

First*

Last*

Cell*

Email Address*

Is Mother Jewish

Health & Transportation

Emergency Contact Information

Emergency Contact Name

Relationship

Address

Work/Mobile Phone

Physician or Medical Facility

Phone

Parental Consent and Transportation Information

I hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately.

Initialize*

I hereby give permission for my child to be transported and participate in field trips during operating hours. Details will be sent to me in advance

Initialize*

Health History and Special Instructions

List any illnesses your child had within past 6 months

List any Sensitivities your child has. Any dislikes you feel we should be aware of?

Does your child have any allergies?

If yes, please list allergies

Does your child have a history of

Physical handicaps Rheumatic fever Heart problems Seizures Asthma Diabetes Other (describe)

Please describe any instructions that would be helpful in caring or for your child, or special medical information needed by the child’s care staff/provider.

Camp T-s

hirt

T-shirt Size

Registration Fee

*I authorize Eastside Torah Center to charge my credit card. Please note that any credit card refund will incur a 5% bank service fee. Process the payment in full ($425/week)

*Name on Card

*Card Number

*Expiration

*CVV Security Code

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