Friendship Circle End of Summer Camp 26

Thurs Aug 27 - NY Aquarium

Mon Aug 31- Empire Adventure Park

Drop off and pick up at Chabad - 74 Maple Ave. Cedarhurst

10:00 AM-2:45 PM

Cost: $55 a day

Your child will need:
Nut free Lunch
Change of clothing if needed (labeled)

Snack will be provided

Limited space available!

Name

First NameLast Name

Primary Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Mothers Cell

Please enter a valid phone number.Format: (000) 000-0000.

Fathers Cell

Please enter a valid phone number.Format: (000) 000-0000.

In case of emergency and a parent can not be reached- Emergency Contact name and number :

Does you child have any allergies? If yes, please detail.

Does your child take any meds during camp hours? If yes, please detail.

Is your child toilet trained? Please explain your child's bathroom habits in detail.

Please list any activities you would not like your child to participate in due to a limitation or medical condition that we should be aware of:

Please list any additional information our staff should know to ensure your child has a safe, and fun experience:

I hereby give permission to the Friendship Circle to transport my child to and from trips. (sign below)

I give permission to the Friendship Circle to use my child’s photo for publicity or on social media?

What days will your child be attending? ($55 dollars a day)

A waiver is required for Empire Adventure Park, kindly sign and then return to this form to submit. SIGN WAIVER HERE

I would like to pay by

Camp ($55 a day)

USDPayment for end of summer camp

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Medical & Emergency Release:My son/daughter has my permission to attend Friendship Circle events. I agree not to hold Friendship Circle liable for any accident, loss or theft that may occur during the course of an event. I hereby give my permission to the physician selected by the Friendship Circle to hospitalize, and/or secure necessary treatment or anesthesia for my child, as named above, in the event that I cannot be reached in an emergency. I hereby give my permission that paramedics may transport my child to the nearest hospital, if necessary. I have indicated any pertinent medical information above. I agree to the terms and conditions of this application. Liability Waiver I will not hold Friendship Circle liable for any accidents, injuries, damage or fatalities which may occur in transit to/from aforementioned events. I also waive all rights to sue Friendship Circle for any of the above mentioned incidents which may occur in transit. Sign your agreement below.