Register - Chabad Culinary Camp - Chabad Jewish Center of Oakland

Please fill out this form as an initial registration for the Jewish Culinary Camp. Confirmation of acceptance will be acknowledged only after this registration form is reviewed and an acceptance letter is received.

Student Information

Name*

First Last

Child's Hebrew Name*

Date of Birth*

MM slash DD slash YYYY

Age*

Gender*

Male

Female

Does your child have previous Jewish Education?*

Yes

If yes, please describe:

What school and grade does your child attend?*

Is the child's birth mother Jewish?*

Yes

Is the child's father Jewish?*

Yes

Were there any conversions or adoptions in your family?*

Yes

If yes, please describe:

Any considerations, such as learning disorder or difficulty, the camp should be aware of? (Confidential):*

Parent Information

Father Name

First Last

Father Cell Phone*

Father Email*

Father Occupation*

Father Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother Name

First Last

Mother Cell Phone*

Mother Email*

Mother Occupation*

Mother's address same as above?*

Yes

Mother Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

Please list two contacts to be used in case of emergencies (other than your home and business numbers).

Emergency Contact 1 (other than parent)*

First Last

Relationship to child*

Cell Phone*

Emergency Contact 2 (other than parent)*

First Last

Relationship to child*

Cell Phone*

Health History

Child's Physician

Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.*

Does your child have an epipen?

Yes

Is your child taking any medication?*

Yes

Please list all medications being taken with the reason

Health History*

Frequent Ear Infection

Seizures and Convulsions

Hypertension

Mononucleosis

Asthma, Wheezing or Shortness of breath

Diabetes

Measles

Mumps

Bleeding/Clotting Disorders

Seasonal Allergies

Other Condition, Illness or Injury

None of the above

Check all that apply. Note dates and add comments in the notes section.

Notes

Please list operations/ injuries / disabilities / recurring illnesses (include dates), or any fears, special diets or needs, learning disabilities, behavioral issues, etc. of which we should be aware

Immunization history

Yes, all immunizations are up to date

Other

(Up to date immunizations are required).

Other

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Jewish Culinary Camp to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Jewish Culinary Camp personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all activities and allow my child to be photographed while participating in Jewish Culinary Camp activities.*

I Accept

Jewish Culinary Camp Payment Agreement

The following is a payment agreement for the Jewish Culinary Camp. The agreement explains the fees, payments plans and refund policies. Please read it through carefully. Payment for Jewish Culinary Camp is $450 for 1 week and $880 for 2 weeks.

Rates:*

Week 1 (June 23-27) - $450.00

Week 2 (June 30 - July 4) - $450.00

Both Weeks - $880.00

Payment Info

Consent*

I accept all the above terms & conditions

Your FULL name here:*

I heard about the Jewish Culinary Camp from:*

Coupon

Credit Card

Today's Total

Register – Chabad Culinary Camp

Chabad Culinary Camp

Student Information

Parent Information

Emergency Contact Information

Health History

Jewish Culinary Camp Payment Agreement

Payment Info

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