Camper Shabbaton Leviim, Maalot, Kerem and Na'aleh '18

Camper name*

First

Last

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Aydah*

Transportation*

All meals are strictly kosher. If you have any food allergies, intolerance, or are a vegetarian please let us know :

Parent name*

First

Last

Phone*

Email

Secondary emergency contact/parent/guardian*

Phone

If we can't reach you on your cellphone, in case of emergency, please provide an alternative means of contact

Medical information

If the applicant has any condition that might require medication, accommodation
and/or special attention, please detail the condition and explain any measures that are needed to provide proper care.
List any relevant medical conditions, and medications and dosages currently being prescribed for use by physician.
Please attach additional/more detailed information if needed:

Name of health Insurance plan:*

Policy Number:*

Name of Policy Holder:*

Group Number:

I give permission for my child to be given the following non-prescription medications

Tylenol
Advil
Claritin

Please alert us to any severe allergies your child may have :

Will your child have medication on the trip?*

Yes
No

Please send all prescription medication in original pharmacy packaging with specific instructions clearly written out.

Terms and conditions:

We agree to permit the applicant to participate in the Camp Yavneh Shabbaton Trip pursuant to the conditions stated in the agreement below:
1. The cost for the trip is $225. Payments should be made to Camp Yavneh no later than December 1st. If submitted after the December 1st deadline, the cost becomes $250. No refund of tuition can be made for cancellations after December 15th. All cancellations must be made in writing.

2. Rules presented to campers on the trip are to ensure the safety and quality of the trip for all participants. Use or possession of drugs, alcohol or weapons; abuse, defacement or theft of property; breaking curfew; unauthorized absence from programs or program sites; or failure to cooperate with Camp Yavneh staff in all facets of the scheduled program, will result in disciplinary action and subsequent consequences for the summer of 2019.

3. Should severe infractions occur, Camp Yavneh reserves the right to dismiss the camper from the trip and immediately transfer the camper home at the expense of the participant’s family, with no refund of any tuition payments.

4. Camp Yavneh may use photographs or videos of the campers in connection with the trip.

5. Camp Yavneh will not be held responsible for theft, loss or damage to campers’ personal property.

6. In the event that Camp Yavneh believes that the camper is in need of medical treatment or hospital consultation, treatment or admission, every effort will be made to contact a parent/guardian for authorization. Should Camp Yavneh be unable to establish contact with a parent/guardian, such care is hereby authorized.

7.We understand that we are responsible for payment of tuition and any additional costs incurred on our behalf.
We certify that we have read the above agreements and regulations, that the information provided is true, and that we will inform Camp Yavneh of any relevant changes.
We understand that our child will abide by the behavioral expectations and rules set by Camp Yavneh as outlined above

Camper name*

Application date*

Parent or Guardian’s agreement to terms*

Full name

Initials

Camp Yavneh will make every effort to accommodate individuals with special needs of all types. In order to do so, it is
the family’s responsibility to provide such information, which will be kept in the strictest confidence, to be shared with
staff on a need-to-know basis.
For the safety and well-being of all participants it is critical that you disclose any
conditions/situations that may affect your child’s experience. Please attach any additional information.

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Camper Shabbaton Leviim, Maalot, Kerem and Na’aleh ’18

Shabbaton

75 years embracing all
Jews in a summer of
recreation and education.

Winter address

Summer address