Please print neatly and clearly Childs Information Last Name First Name Jewish Name 2012/ /26 /1986 Home Address. Last Name Occupation Work #

Transcription

1 CHABAD NESHAMA CAMP ב"ה Chabad Lubavitch of W. Brighton Beach Manhattan Beach Please print neatly and clearly Childs Information Last Name First Name Jewish Name Date Of Birth 12 /26 /1986 Home Address School Grade 2012/13 Age Gender Apt# City, State, Zip Home Phone Parents Information Fathers First Name Last Name Occupation Work # Cell Phone # Address Jewish Mothers First Name Cell Phone # Marital Status Y Last Name Occupation Work # Address Jewish Y N N Married Separated Widowed Divorced 2997 Ocean Parkway Brooklyn, NY

2 CHABAD NESHAMA CAMP ב"ה Chabad Lubavitch of W. Brighton Beach Manhattan Beach Please indicate your option: Younger Division Coming out of Pre-K - 2nd grade Middle Division Coming out of 3rd grade - 4th grade Older Division Coming out of 5th grade - 7th grade Pioneer Program Grades 8-9 Full Season July 1 August 16 Week 1 July 1 July 5 Week 2 July 8 July 12 Week 3 July 15 July 19 Week 4 July 22 July 26 Week 5 July 29 August 2 Week 6 August 5 August 9 Week 7 August 12 August 16 $1,950 $235 $235 $235 $235 $235 $235 $235 $2,150 $310 $310 $310 $310 $310 $310 $310 $2,350 $335 $335 $335 $335 $335 $335 $335 July 22- August 2 $700 Please check all that apply: Door-to-Door Transportation $50.00 Per Week Early Care 8:00AM 9:00 AM $15.00 Per Week After Care 4:00 PM 5:00 PM $15.00 Per Week After Care 4:00 PM 5:00 PM $15.00 Per Week PROMO CODE For office use only Early Bird $ Off Full Summer $50.00 Off Scholarship Siblings Discount $50.00/ Off Refer A Friend $ Off 2997 Ocean Parkway Brooklyn, NY

3 CHABAD NESHAMA CAMP ב"ה Chabad Lubavitch of W. Brighton Beach Manhattan Beach TERMS AND CONDITIONS Child s Name Parent/Guardian Name Relationship to Child 1. PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Chabad Neshama Camp 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 $ non-refundable deposit to accompany registration. This will be credited towards your tuition. The balance is due by June 15 th, 2013 and is non-refundable after that date. 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 less the $ registration deposit. 4. SWIMMING: I hereby give my child permission to go swimming on the Coney Island Beach every day. I further give my child permission to swim in the pool located at Pacplex, located at 1500 Paerdegat Ave. N. Brooklyn, NY I give Chabad Neshama Camp my permission to apply sunscreen as needed. Sunscreen must be labeled with your child s name and dated as it does expire. 5. IMAGES, ETC.: Permission is hereby given to use in promoting the Camp and in other ventures directly relatin g 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 Chabad Neshama Camp and its officers, servants or assigns from any liability concerning our child s involvement in Chabad Neshama Camp and further agree that the use of any premises during the Chabad Neshama Camp day is made at the risk of the registrant. 7. DOOR-TO-DOOR TRANSPORTATION: Pick-up and drop off times are determined by the transportation provider, based on area and number of children enrolled in Door-to-Door transportation. The bus will arrive at the designated location and wait 2-3 minutes for a child and then depart. If a camper missed the van, the van will not return to pick up the camper. Chabad Neshama Camp does not guarantee consistency in the pick-up and drop off times. When camp returns from a trip after 4:00 pm, there will be no Door-to-Door transportation. I have read and agree to all of the terms and conditions in this Registration Form. I am including a nonrefundable registration deposit of $ along with submission of this form. I further agree to remit the full tuition and any other fees by June 15 th, I further agree to send in the Health Form by June 15 th, A child without a Health Form will not be allowed to join camp, this is the law and we cannot make any exceptions. Please make checks payable to: Chabad. Parent/Legal Guardian: Date: 2997 Ocean Parkway Brooklyn, NY

4 INCOME ELIGIBILITY FORM FOR THE SUMMER FOOD SERVICE PROGRAM (For Use by Camps and Closed Enrolled Sites) Attachment SFSP Please complete the following form using the instructions below. Sign the form and return it to: [Name of Sponsor]. If you need help, call [phone number of Sponsor] Follow these instructions, if your household gets SNAP (Food Stamps) TANF or FDPIR: Part 1: List participant s name and a SNAP (Food Stamp), TANF or FDPIR case number. Part 2: Skip this part. Part 3: Skip this part. Part 4: Sign the form. A Social Security Number is NOT required. Part 5: Answer this question if you choose to. If your household includes a FOSTER CHILD, use one application for the whole household and follow these instructions: Part 1: Enter the child s name. Part 2: Please contact us at [phone number of Sponsor] Part 3: Complete this part if you are applying for other children in the household and you did not enter a SNAP (Food Stamp), TANF or FDPIR case number in Part 1. Part 4: Sign the form. If Part 3 was completed, provide the last four digits of the signing adult s Social Security Number. Part 5: Answer this question if you choose to. ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions: Part 1: List each participant s name. Part 2: Skip this part. Part 3: Follow these instructions to report total household income from last month. Column A Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends who live with you). You must include yourself and all children living with you. Attach another sheet of paper if you need to. Column B Gross income last month and how often it was received. Next to each person s name, list each type of income received last month, and how often it was received. In Box 1, list the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly). In box 2, list the amount each person got last month from welfare, child support, alimony. In box 3, list Social Security, pensions, and retirement. In box 4, list ALL OTHER INCOME SOURCES including Worker s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance. Column C Check if no income: If the person does not have any income, check the box. Part 4: An adult household member must sign the form and include the last four digits of his or her Social Security Number, or mark the box if he or she doesn t have one. Part 5: Answer this question if you choose to. Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a SNAP, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program. Non-discrimination Statement: In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to: USDA, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C or call (866) (voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

5 Part 1. Children enrolled in Camp or Closed Enrolled Sites. Names (First, Middle Initial, Last) Attachment 10, Continued 2013 SFSP SNAP (Food Stamp), TANF or FDPIR case # (if any). Skip to Part 4 if you listed a case #. Part 2. Foster Child Foster children eligible for free and reduced-price meals regardless of household income. If a foster child lives with you, please contact [name of Sponsor] at [phone number]. Complete Part 3 if you are applying for other children in your household and you did not enter a SNAP (Food Stamp), TANF or FDPIR case number in Part 1. Part 3. Total Household Gross Income You must tell us how much and how often A. Name (List everyone in household, including children) B. Gross income and how often it was received Example: $100/monthly $100/twice a month $100/every other week $100/weekly 1. Earnings from work 2. Welfare, child 3. Social Security, before deductions support, alimony pensions, retirement, 4. All Other Income 1. $ / $ / $ / $ / 2. $ / $ / $ / $ / 3. $ / $ / $ / $ / 4. $ / $ / $ / $ / 5. $ / $ / $ / $ / 6. $ / $ / $ / $ / 7. $ / $ / $ / $ / 8. $ / $ / $ / $ / 9. $ / $ / $ / $ / 10. $ / $ / $ / $ / 11. $ / $ / $ / $ / 12. $ / $ / $ / $ / C. Check if NO income Part 4. Signature and Social Security Number (Adult must sign) An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (See Privacy Act Statement on the back of this page.) I certify that all information on this form is true and that all income is reported. I understand that this information is being given for the receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. Sign here: X Print name: Date: Address: Phone Number: Last four digits of Social Security Number: I do not have a Social Security Number Part 5. Participant s ethnic and racial identities (optional) Mark one ethnic identity: Mark one or more racial identities: Asian American Indian or Alaska Native Hispanic or Latino Not Hispanic or Latino White Native Hawaiian or Other Pacific Islander Black or African American Don t fill out this part. This is for official use only. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12 Total Income: Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: Categorical Eligibility: Date Withdrawn: Eligibility: Free Reduced Denied Reason: Determining Official s Signature: Date: Confirming Official s Signature: Date: Follow-up Official s Signature: Date:

6 HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS (This side to be filled in by parent before presentation to physician) NAME OF PROGRAM / / M F CHILD'S LAST NAME FIRST NAME BIRTHDATE SEX Home Address: Parent or Guardian: Place of Employment: Father (Guardian) Mother (Guardian) In case of emergency, notify: If Parent, Guardian are not available in an emergency, notify: 1. or 2. Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance: Yes No (If yes, state type of exposure: ) HEALTH HISTORY: (Check box if child has had afflictions, give appropriate dates) Allergies Rheumatic Fever Hay Fever Seizures Diabetes Asthma Chicken Pox Poison Ivy, etc. Insect Stings Penicillin Other Drugs Food Other Past Illnesses Operations or Serious Injuries (Dates) Hospitalization (Dates) Chronic or Recurring Illness Any specific activities to be encouraged? Conditions that require activity to be restricted? Permission for all program activities unless otherwise noted by Dr. Appliance worn (glasses, contacts, etc.) Medication taken Suggestion from Parent/Guardian CONSENT FOR EMERGENCY MEDICAL TREATMENT I do hereby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Relationship Signature Date Tel.# Department of Health and Mental Hygiene The City of New York Bureau of Food Safety and Community Sanitation DCR 7 (Rev. 2/04)

7 PHYSICAL EXAMINATION (To be filled out by Physician please note information on reverse side) The purpose of this health record is to provide the staff with pertinent information which will help to serve the needs of this child in Day Camps and Afterschool and Youth Center programs. IMMUNIZATION HISTORY This is a record of dates of basic immunization and most recent booster doses. DTaP, DTP, DT, Td Date Date Date Date Date Polio Date Date Date Date Date MMR Date Date Date Hemophilus Influenzae type b (Hib) Date Date Date Date Hepatitis B Date Date Date Date Varicella Date Date Pneumococcal Conjugate (PCV) Date Date Date Date Date Other Date Other Date Other Date MEDICAL EXAMINATION To be filled out by licensed physician. Examination is acceptable when performed no more than 12 months prior to arrival at camp. Code: S = Satisfactory X = Not Satisfactory (Explain) 0 = Not Examined General Appearance Genitalia Height Weight Blood Pressure Posture & Spine Throat - Tonsils Nose Teeth Abdomen Hernia Feet Lungs Skin Hgb. Test (Date) Urinalysis (Date) Eyes Vision w/glasses Extremities Heart Ears Hearing Neurological Findings Describe Abnormal Findings and/or Handicapping Conditions Allergy: (Please specify) Recommendations and restrictions while in camp: Special Diet Special Medicine (dose, route of administration, when should it be administered) Is parent/guardian sending special medicine? Activity Restrictions Swimming Diving General Appraisal: I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above. EXAMINING PHYSICIAN (SIGNATURE) M.D. PHYSICIAN'S NAME (PLEASE PRINT) Telephone Address Date of Examination DCR 7 (Rev. 2/04) ZIP CODE