Camp Moshava Online Registration

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PLEASE REGISTER MY CHILD IN: *

July 4 - Aug 15(6 WKS)July 4 – Aug 1 (4 WKS)Aug 1 – Aug 15 (2 WKS)

As a new camp family, I heard about Camp Moshava through

Campers Gender *

Camper's First Name *

Camper's Last Name *

Home Address: *

City *

Province/State *

Postal / Zip Code *

Home Phone *

Date of Birth (MM/DD/YY) *

School *

School Phone#

Present Grade (until June 2012) *

Camper E-mail Address

Health Card #

Version Code (ON) or Exp Date(QC)

T- Shirt Size (free camp t-shirt)

REFERENCE

ALL NEW CAMPERS MUST PROVIDE A REFERENCE. AT LEAST ONE MUST BE A TEACHER OR PRINCIPAL AT CHILD’S SCHOOL.

1st REFERENCE NAME

1st REFERENCE POSITION

1st REFERENCE PHONE

2nd REFERENCE NAME

2nd REFERENCE POSITION

2nd REFERENCE PHONE

HEALTH INFORMATION

Please note you will also receive a detailed medical form that will need to be completed.

ALLERGY/BEHAVIOUR INFORMATION

Does camper have any Food or Drug allergies: *

If yes, list the specific allergy:

Does camper have any behaviour issue? *

If yes, please specify:

Please upload a recent Photograph

PARENTAL INFORMATION

Father's Last Name *

Father's First Name *

Father's Profession:

Father's Business Phone

Father's Cell Number:

Father's Fax

Dad are you an alumni of Moshava?

Father's E-mail Address:

Dad if yes, what year(s) did you go?

Mother's Last Name *

Mother's First Name: *

Mother's Profession:

Mother's Business Phone:

Mother's Cell Number:

Mother's E-mail Address:

Mother's Fax

Mom are you an alumni of Moshava?

Mom If yes, what year(s) did you go?

Please provide email address where camp information should be sent:

Synagogue Affiliation:

Parents Marital Status *

Name of Custodial Parent(s):

Custody/visitation arrangements, please explain:

Please provide us with copies of legal documentation or a letter

EMERGENCY CONTACT

EMERGENCY CONTACT # 1 Name *

EMERGENCY CONTACT # 1 Home Phone *

EMERGENCY CONTACT #1 Business Phone

EMERGENCY CONTACT #1 Cell Phone

EMERGENCY CONTACT #1 Home Address

EMERGENCY CONTACT #1 Relationship

EMERGENCY CONTACT # 2 Name

EMERGENCY CONTACT # 2 Home Phone

EMERGENCY CONTACT # 2 Business Phone

EMERGENCY CONTACT #2 Cell Phone

EMERGENCY CONTACT #2 Home Address

EMERGENCY CONTACT #2 Relationship

PARENTS’ DECLARATION

1. Payments I/We have enclosed and shall make all payments of fees in accordance with the Rate Sheet provided by the Camp.

2. Medical and Personal History Profiles I/We have listed the Camper’s physical and mental/psychological health problems and I/We am/are willing to discuss with the camp Director or consultants any concerns they may have about the Camper. Any inaccurate or deliberately misleading information is grounds for cancellation of the Camp Moshava enrolment of the Camper without refund. I/We understand that if there is any change in the Camper’s health (physical and/or mental/psychological) or if the Camper becomes exposed to an infectious disease prior to camp, the camp must be so notified.

3. Further Enquiries I/We acknowledge that Camp Moshava may make enquiries regarding the Camper and his/her personality, social skills, and behaviour.

4. Emergencies I/We give the Camp and its staff and officials the right in case of emergency to act on my/our behalf to protect the best interests of the Camper.

5. Authorization In the event that I/we and the Emergency Contact(s) named in this application cannot be contacted on a basis and time frame consistent with the best interests of the Camper, the undersigned Parent(s) /Guardian(s) hereby authorize Camp Moshava to designate the licenced physician(s) or other medical professionals who will authorize and supervise the treatment to be provided to the Camper including hospitalization, injection, anaesthesia, surgery or other treatment of the Camper to the extent which in the opinion of such physician(s) is necessary for the health and well-being of the Camper named in this application.

6. Indemnity and Release In consideration of the enrolment of the Camper in Camp Moshava, the undersigned Parent(s)/Guardian(s) hereby release(s) Camp Moshava, its officers, corporate directors, employees, agents and volunteers (collectively, the “Camp Community”) from, and agree to indemnify and hold the Camp Community harmless against and from any and all liability, claims and costs resulting from any injury or illness or damage, however caused, which may be suffered or incurred by the Camper and which arises or, is, in any way, connected with or occurs during the Camp Moshava session attended by the Camper, including Camp Moshava trips and other travel days, at any location within or outside of the Camp Moshava camp site and the said the undersigned Parent(s)/Guardian(s) hereby assume the risk of such liability, claims and costs.

7. Cancellation and Refunds I/We acknowledge that we are aware of and accept the rules and conditions set out under the Cancellation and Refund Policy set forth on the Camp Moshava website (www.campmoshava.org)and in the material provided to us by the Camp.

8. Termination of Enrolment I/We acknowledge that the Director of Camp Moshava has the right to terminate the enrolment of the Camper at any time and to require that the Camper be removed from the Camp should the Director be of the opinion that to do so will be in the best interest of the camp, the Camper or other members of the Camp community.

9. Permission to Participate I/We hereby permit and consent to the participation of the Camper in any and all camp activities and all supervised activities on or off camp property. Photos and Videos may be used for promotional purposes.

10. Personal Property I/We acknowledge thatCamp Moshava is not responsible for damage to or loss of the Camper's property and I/we hereby release the Camp from any claims in that regard.

11. Certification I/We certify that all information contained in this registration form is complete and accurate.

Processing of this Application: This registration (one camper per form please), together with the required cheques or VISA Authorization for the total applicable camp fees for each Moshava camper in your family should be forwarded to Camp Moshava, 296 Wilson Avenue, Toronto, Ontario, M3H 1S8. Full details of our fees and dates are found on the rate sheet that you received with this Registration and should be reviewed carefully.

PLEASE NOTE: Registration forms will be fully processed once the appropriate payment is received by the deadline, as well as the return of the medical/information form (which will go out at a later date). Completion of this form and the depositing of your payments does not constitute acceptance of this registration form. Confirmation of acceptance will be sent from the camp office.

I /We hereby apply for enrolment of the Camper named above for the 2012 Moshava camping season and I/we hereby confirm and agree to the Parents Declaration: *

Payments

Deposit

When paying your deposit by check please send it to 296 Wilson TO, ONT M3H 1S8 at time of registration.

When giving a credit card number by phone, you must call the office at (416) 630-7578 with credit card information.

When giving paying online a 2% surcharge, will be added

Method of payment (Deposit) *

I am paying my balance by post dated check

I choose to give a credit card number by phone

I choose to pay on-line.

Balance (payment method required at time of registration)

When paying your balanceby check please send it to 296 Wilson TO, ONT M3H 1S8 at time of registration.

When giving a credit card number by phone, you must call the office at (416) 630-7578 with credit card information.

When giving paying online a 2% surcharge, will be added

Method of payment *

I am paying my balance by post dated check

I choose to give a credit card number by phone

I choose to pay on-line.

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Once you answer math problem below, you will be redirected to the Thank You! page this will confirm the successful completion of your registration form.