Camp Application

1. Camper Info
Full Name*
First Name Last Name
Nickname?*
E-mail
Teen's Cell Phone*
Birth Date*

Month Day Year
Gender*

MaleFemale
School?*
Current Grade?*
Height?*
Weight?*
T-Shirt Size?*
Weeks Attending ?*

Week 1 - June 30Week 2 - July 7Week 3 - July 14Week 4 - July 21
2. Family Info

Address*

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

Marital Status?*
How did you hear about us?*
Any adoption or conversion in the family?*
If yes please explain:
Father's Full Name*
First Name Last Name
Father's E-mail*
Father's Phone Number*

Father's Address If different than above

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

Mother's Full Name*
First Name Last Name
Mother's E-mail*
Mother's Phone Number*

Mother's Address if diffrent than above

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

Is Mother Jewish?* NOTE: We accept conversions recognized by the rabbinical courts in Israel (Rabanut of Israel).
3. Health and Transportation
Insurance Provider*
Name of Policy Holder*
Member ID #*
Emergency Contact Name*
First Name Last Name
Relationship?*

Address*

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

Work/Mobile Phone*
Physician or Medical Facility*
Provider Phone Number*
4. 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
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 handicapsRheumatic feverHeart problemsSeizuresAsthmaDiabetesOther
If other please explain
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.
Registration fee*

I authorize a $100 non refundable deposit to be charged immediately and credited toward tuition (will be refunded if the application is not accepted).
Upload photo of camper*
Code of Conduct - click here to read
Code of Conduct*

I have read these rules and reviewed them with my child and understand them fully. We certify that my child will adhere to this code. We understand that any violation of this Code of Conduct may result in me being suspended from camp. Must be signed by parent and camper.
Remaining balance payment options*

Option 1: Pay by check to ETC and write cteen camp in memo. If check is not received by June 1st, I authorize the ETC to charge the balance to my credit card.Option 2: I authorize the Eastside Torah Center to charge the full remaining balance to my credit card upon acceptance.
Weekly Camp Fee & Deadlines:
$550; Earlybird $525 if registered by March 14
$600 Late registration after May 15th, and will be on wait list
Total

$0.00

Payment

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Postal / Zip Code

Country

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Camp Application

1. Camper Info

2. Family Info

3. Health and Transportation

4. Parental Consent and Transportation Information

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