JUDA Winter Camp
Chabad Denver North
First and Last Name
*
First Name
Last Name
Name Child is called:
*
Child's Age
*
5
6
7
8
9
10
11
12
Child's current grade.
*
Gender:
*
Male
Female
Medical Condition(s)
*
Yes
No
Please specify your child's medical condition(s):
Is your child taking any medication at home?
*
Yes
No
If yes, please specify.
Does your child have any known allergies? (food, season, insects, etc.)
*
Yes
No
If yes, please specify reaction and treatment.
Is there anything special we should know about your child?
*
I would like to register a second child:
YES
NO
First and Last Name
*
First Name
Last Name
Name Child is called:
*
Child's Age
*
5
6
7
8
9
10
11
12
Child's current grade.
*
Gender:
*
Male
Female
Medical Condition(s)
*
Yes
No
Please specify your child's medical condition(s):
Is your child taking any medication at home?
*
Yes
No
If yes, please specify.
Does your child have any known allergies? (food, season, insects, etc.)
*
Yes
No
If yes, please specify reaction and treatment.
Is there anything special we should know about your child?
*
I would like to register a third child:
YES
NO
First and Last Name
*
First Name
Last Name
Name Child is called:
*
Child's Age
*
5
6
7
8
9
10
11
12
Child's current grade.
*
Gender:
*
Male
Female
Medical Condition(s)
*
Yes
No
Please specify your child's medical condition(s):
Is your child taking any medication at home?
*
Yes
No
If yes, please specify.
Does your child have any known allergies? (food, season, insects, etc.)
*
Yes
No
If yes, please specify reaction and treatment.
Is there anything special we should know about your child?
*
Home Phone:
-
Area Code
Phone Number
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Information:
Parent #1 Name:
*
First Name
Last Name
Relationship to child:
Jewish
*
Yes
No
Other
Email:
*
example@example.com
Cell Phone:
*
-
Area Code
Phone Number
Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone:
-
Area Code
Phone Number
Parent #2 Name:
First Name
Last Name
Relationship to child:
Jewish
Yes
No
Other
Email:
example@example.com
Cell Phone:
-
Area Code
Phone Number
Address: (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone:
-
Area Code
Phone Number
During camp hours the best way to reach us is:
*
Call mother's cell phone
Call father's cell phone
Text mother
Text father
Family Information
Family Synagogue Affiliation:
Marital Status of Parents:
Languages spoken at home other than English:
Are there any conversions in the family?
*
Yes
No
Other
If yes, please specify who.
Current school:
Attended from
blanks
to
blank
.
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Emergency Contact/Authorized Pick Up Information
Please share at least one emergency contact, in addition to parents. Please include name, relationships, address, and phone number.
Contact #1
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
Relationship
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
This contact is also authorized to pick my child/children up.
*
Yes
No
Contact #2
First Name
Last Name
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
This contact is also authorized to pick up my child from school.
Yes
No
Contact #3
First Name
Last Name
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
This contact is also authorized to pick up my child from school.
Yes
No
Signature of Parent or Guardian
*
Date:
*
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Grandparent/Special Person Information
(Optional)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone
-
Area Code
Phone Number
Maternal
Paternal
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
Email
example@example.com
Maternal
Paternal
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
Email
example@example.com
Maternal
Paternal
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
Maternal
Paternal
Email
example@example.com
Back
Next
Medical and Emergency Form
Doctor's Name
*
First Name
Last Name
Name of Practice
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
In case of an emergency, my preferred hospital is:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Does your child/children have medical insurance?
*
Yes
No
Insurance Provider
*
Dentist's Name
*
First Name
Last Name
Name of Practice
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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Statement of Authorization
Emergency Medical Treatment - I hereby give my consent to call a doctor or emergency medical service and for that doctor or emergency service to provide emergency medical or surgical treatment to my child.
*
Yes
No
Photo Release - I hereby grant my permission for my child's photo to be taken and shared in camp newsletters and updates.
*
Yes
No
Other
Media Release - I hereby grant my permission for my child's photo to be taken and used in flyers, and/or for any other advertisement purposes.
*
Yes
No
Other
Signature
*
Date:
*
Back
Next
Cost: $300 per child: Includes all trips and activities
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Winter Camp
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