Kool n Kosher after school

camp
Child's name

Se
x

Primary parent / guardian name.

Birthday
____/____/_______

Home #:
(_____)-_____-______

Grade School name

______
_
Cell #:
Alternate #:
(_____)-_____Ext.
______
(_____)-_____-______
___

Address:

Other parent / guardian name.

Home #:
(_____)-_____-______

Cell #:
(_____)-___________

Alternate #:
Ext.
(_____)-_____-______
___

Address:

Special health problems: Yes No If yes,

specify:

Allergies to food or drugs: Yes No If yes,

list:

Regular medications: Yes No If yes, specify:

If you checked "yes", will child require medication during camp hours? Yes No
Limitations (e.g. stair climbing, participation in gym) Yes No
Physician name:
Address:

Phone number
Ext.
(_____)-_____-______
_______
Phone number
Ext.
(_____)-_____-______
_______

Dentist name:
Address:

Insurance provider:

Alt. Phone number

Ext.
(_____)-_____-______
_______
Alt. Phone number
Ext.
(_____)-_____-______
_______
Policy #:

List up to four close relatives and /or neighbors who can pick up your child in case you or the other parent cannot be reached. Child will
only be released to persons listed below.

Name

Relationship

Primary day phone

(_____)-___________
(_____)-___________
(_____)-___________
(_____)-___________

Cell phone
(_____)-_____-______

Alt. phone
Ext
(____)-_____-_____ _____

(_____)-_____-______

(____)-_____-_____ _____

(_____)-_____-______

(____)-_____-_____ _____

(_____)-_____-______

(____)-_____-_____ _____

Please list the names of persons who may NOT visit, contact, or pick up your child from camp.
Payment

Registration Fee $
Membership Fee $
Extended Hours $
Fee
Total Camp Payment
Fee
$ options
Payment
Amount Due
$ method
Pay camp fees in full at the time of registration Cash
Check
Pay camp
fees
before
Money
I am responsible
for bring
my every
child to month
camp and
pickingsession
up my child at designated
time. Repeated lateness will
Order

Visa
result in termination. I agree to pay $1 for every minute late pickup.
I am responsible for bringing my child to camp on time.
American Express
If my child does not follow the camp rules, my child will be terminated.
All remaining
camp fees will be refunded.
Master
Card
By signing, I, the
parent
or
guardian,
consent
to
the
enrollment
of
the
child
in
camp
for
the 2014-2015 school year. I
Discover
understand some of the aforementioned activities pose risk of injury. Under any circumstances the camp shall not be liable
for any injuries that result from my childs participation in camp, unless such injury is a result of negligence from camp staff.
I consent for my child to receive medical treatment in case of an emergency.
Parent signature
Parent signature