Shabbaton at Camp Cedarkirk

SHABBATON 2018
OCTOBER 26 - 28
Congregation Rodeph Sholom & Camp Ramah Darom
Assistant Director Rachel Dobbs-Schwartz

*One application per camper.

* Camper's Full Name

* Birth Date

Child's Birth date

* Age

* Grade in Sept '18

* Address

* City

* State

* Zip Code

* Home Phone

* Parent's Email

* Parent #1 Name

* Parent #1 Home Phone

* Parent #1 Cell Phone

* Parent #1 Work Phone

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

* Parent #2 Home Phone (N/A if not applicable)

* Parent #2 Cell Phone (N/A if not applicable)

* Parent #2 Work Phone (N/A if not applicable)

INFORMATION:

SHABBATON IS FOR CHILDREN IN 3RD - 7TH GRADES AND ASSISTANTS IN 8TH - 12TH GRADES.
FRIDAY, OCTOBER 26TH AT 4:00 PM TO SUNDAY, OCTOBER 28TH AT 12PM.
DETAILED SCHEDULE, PACKING LIST AND TRANSPORTATION INFORMATION WILL BE PROVIDED BY OCT 1ST.
ANY MEDICATIONS SHOULD BE LABELED AND THE WRITTEN INSTRUCTION SHEET MUST BE COMPLETED.
INCLUDES ALL MEALS, SNACKS, ACTIVITIES AND GROUP TRANSPORTATION.

* Shabbaton

3rd - 7th graders ($150)Assistants: 8th - 12th graders ($75)

Total Payment

LIST TWO CONTACTS IN CASE OF AN EMERGENCY

* 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 disabilities or problems 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

Fri, April 26 2024 18 Nisan 5784