Camp Rodeph Sholom

CAMP RODEPH SHOLOM
June 7 - 11 and June 14 - 18

9:00 a.m. - 3:00 p.m.*
*(Before or after care available)

*One application per camper.

* Camper's Full Name

* Birth Date

Grade in Sept 2021

Age

* Address

* City

* State

* Zip Code

* Parent #1: Name

* Parent #1: Email

* Parent #1 Cell Phone

Parent #1 Work Phone

Parent #1: Home Phone

Parent #2 Name (N/A if not applicable)

Parent #2: Email

Parent #2 Cell Phone

Parent #2 Work Phone

Parent #2 Home Phone

INFORMATION:

CAMP SESSION IS WEEKDAYS FROM MONDAY, JUNE 7TH - FRIDAY, JUNE 11TH AND MONDAY, JUNE 14TH - FRIDAY, JUNE 18TH.
Campers may be asked to bring a change of clothes for any messy activities. A schedule will be sent out via email in May.
ANY medications should be labeled with written instructions completed and turned into the Camp Director.
KOSHER LUNCHES MAY BE PURCHASED EACH DAY OR YOU MAY PACK A DAIRY OR VEGETARIAN LUNCH. LUNCH ORDERS LISTED BELOW ARE $7.50 PER DAY. SNACKS WILL BE PROVIDED DAILY.
Campers will have the opportunity to register for chuggim (Intensive style specialties) for the morning then have a rotation so camp style activities for the afternoon.
Afternoon Camper Groups will be broken up as follows:
- PreK - 1st
- 2nd/3rd
- 4th/5th
- 6th/7th
- CIT: 8th/9th Grade
- Junior Counselor: 10th & 11th Grade
- Senior Counselor 12th Grade OR Over 18 Years old

* Camp Tuition

2 Weeks Members: ($500) June 7 - 11 AND June 14 - 182 Weeks Non-members: ($625) June 7 - 11 AND June 14 - 181 Week Members: ($320) June 7 - 111 Week Non-Member: ($450) June 7 - 111 Week Members: ($320) June 14 - 181 Week Non-Member: ($450) June 14 - 18CIT Option (Grades 8 & 9) - Please choose option(s) in section below.

PBJ or Bagel with cream cheese or butter - Alternative

Please note any days and substitutions for the lunches ordered.

Extended Care (Member Rate)

Extended Care AM (7:30am - 9:00am) $10/Day

Extended Care PM (3:00pm - 6:00pm) - $15/dayPlease enter the number of days you would like to add before or after care for your child.

Extended Care (Non Member Rate)

Extended Care AM (730-900AM) $15/Day

Extended Care PM (3:00pm - 6:00pm) - $25/dayPlease enter the number of days you would like to add before or after care for your child.

CIT Tuition

Members: ($250) June 7 - 11 AND June 14- 18Non-members: ($375) June 7 - 11 AND June 14- 18Members: ($175) June 7 - 11 (Week #1 Only)Non-Member: ($200) June 7 - 11 (Week #1 Only)Member: ($175) June 14 - 18 (Week #2 Only)Non-Member ($200) June 7 - 11 (Week #1 Only)Interview with Director required before approval. CIT Program is for campers who are accepted into the counselor in training program.

Donation (optional)

Thank you for kind donation for children in our summer camp program.

Total Payment

LIST TWO ADDITIONAL CONTACTS IN CASE OF AN EMERGENCY
*Please have Emergency Contacts be someone other than those listed as Parents and be allowed to pick up the child, if needed.

* Contact Number 1 Name

* Contact Number 1 Phone Number

Contact Number 2 Name

Contact Number 2 Phone Number

Please list all allergies

Current Medications

Are there any additional health or behavioral concerns, medications, or allergies of which we should be aware?

* Child's Physician Name

Child's Physician Phone Number

* Insurance Company Name

* Insurance Company Policy #

PHOTOCOPY OF HEALTH INSURANCE CARD NEEDED

* I hereby give permission for my child (fill in name)

to participate in the programs at Congregation Rodeph Sholom including off campus trips. In the event of an emergency, surgical or otherwise, and I cannot be reached, I hereby give permission for my child to be transported to the nearest medical facility and specifically authorize the representative of Congregation Rodeph Sholom to select a physician and/or authorize medical treatment, including hospitalization, anesthesia, injection, surgery or other measures which he/she feels are in the best interest of my child. Congregation Rodeph Sholom is hereby released and held harmless from any claim, judgment, awards, settlements, or damages to any person or property arising directly or indirectly out of my child's participation in the programs at Rodeph Sholom, including off campus trips or the Congregation's selection of physician, hospital, or any other medical service for my child in a medical emergency, or in connection with the rendering of any such medical treatment.

* Parent 1/Guardian Signature

* Date

Parent 2/Guardian Signature (N/A if not applicable)

Date

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