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LUBAVITCH DAY CAMP OF MONSEY 2012 - 5772 REGISTRATION & HEALTH FORM
Childs Last Name: _________________________________ First Name: _________________________________________ Fathers Name: ___________________________________ Mothers Hebrew Name (for __________________________ :) Home Phone: ________________________Mothers Cell: _________________________Fathers Cell: ________________ Occupation: ______________________________________ Work Phone: ________________________________________ Address: _________________________________________________ Fathers Email:_______________________________ City: _________________________ State: ____ Zip: _____________ Mothers Email: ______________________________ Age: ____ Hebrew Date of Birth: _______________________ English Date of Birth: ________________Grade Entering: ___ Please indicate which session your child will be registered for: Both Sessions: /' June 26th August 16th/ " Session 1: /' June 26th July 20th/ ' Session 2: /' July 23rd August 16th/ "

1st Camp T-shirt is included with your registration. $10 for each additional shirt. Number of additional shirts:____ Please indicate your childs T-shirt size. Remember t-shirts can run small and can shrink. Youth Small (6-8) Medium (10-12) Large (14-16) X-large (18-20) Adult small Adult medium Adult large What activities does your child enjoy? _____________________________________________________________________ Is there anything special that you would like us to know about your child? _________________________________________ ____________________________________________________________________________________________________ EMERGENCY CONTACT INFORMATION Emergency Contact _____________________________________ Relationship __________________________________ Home Phone ____________________ Work Phone __________________________ Cell Phone _____________________ ALLERGIES (Please list any allergies, reaction & management of reaction) Medication Allergies ________________________________________________________________________________ Food Allergies _____________________________________________________________________________________ Other Allergies _____________________________________________________________________________________
1. PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of LUBAVITCH DAY CAMP (LDC) both on and off site, trips, transportation to and from trips etc., unless I advise you otherwise in writing. 2. PAYMENT AND CANCELLATION: Payment terms are a $200.00 NON-refundable deposit (to be credited towards tuition) to accompany registration. The balance is due by June 1st, 2012. Camp fees include all trips, activities and workshops. Camp fees are NON-refundable for late arrivals, cancelations, missed weeks, or early departures. Any cancelations before June 1st, 2012 are refundable in full, minus deposit. After June 1st a 50% refund (minus deposit) will be granted to any total or partial cancelation. If payment in full has not been received by June 1st, 2012 we reserve the right to cancel your registration. 3. DISMISSAL OF CAMPER: Parent fully understands and agrees that the Camp reserves the right to dismiss, in its sole discretion, any Camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the Camp or his fellow campers or who violates camp rules and regulations. In the event of dismissal, tuition will be refunded on a pro-rated weekly basis. 4. MEDICAL CARE: In case of emergency, I hereby give permission to the physician as named on this form or if unavailable another M.D. selected by the camp Director, to hospitalize, to secure proper treatment for and to order injection, anesthesia, or other procedure deemed necessary for my child. Every effort will be made to contact the parent/guardian and emergency contacts first. Should it be necessary for the well being of the camper to utilize outside medical or dental services all expenses involved will be paid for by the Parent. To the best of my knowledge, my child is in good health and I will notify the camp if he/she is exposed to any infectious diseases. I understand that my child may be dismissed during a camp day, due to illness, at the discretion of the camp, and I agree to abide by the Directors decision. 5. IMAGES, ETC.: Permission is hereby given to use in promoting the Camp and in other ventures directly relating to the Camp (i) digital, photographic and video images or likenesses of camper; audio of camper; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by camper or originating from Camp or from a Camp-related activity. 6. INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless LUBAVITCH DAY CAMP (LDC) and its officers, servants or assigns from any liability concerning our childs involvement in LDC and further agree that the use of any premises (including off-campus trips & swimming) during the LDC camp day is made at the risk of the registrant.

I have read and agree to all of the terms and conditions in this Registration Form. I am including a $200.00 NON-refundable registration deposit along with submission of this form. I further agree to remit the full tuition and any other fees by June1st, 2012.

Signature of parent ______________________Print full name___________________ Date _________

Lubavitch Day Camp 45 Jacaruso Drive Spring Valley, NY 10977
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845.418.5170 ldcmonsey@gmail.com