Chabad Winter Camp is a camp dedicated to enriching the lives of children from diverse Jewish backgrounds and affiliations through a stimulating camping experience. CWC is part of the largest and fastest growing network of day camps, enjoying a reputation as a pioneer in Jewish camping, with innovative ideas and creative activities, to both provide enjoyment and inspire children to try new and exciting things! * Early bird special * $100 off per child if registered before Dec. 6! Where did you hear about us? 1. Child/ren’s Information Number of children being registered Child 1 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($450 per week) Week 1 Dec. 23 - 27Week 2 Dec. 30 - Jan 3 Medical Information Child 1: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? Child 2 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($450 per week) Week 1Week 2 Medical Information Child 2: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? Child 3 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($450 per week) Week 1Week 2 Medical Information Child 3: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? Child 4 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($450 per week) Week 1Week 2 Medical Information Child 4: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? If you have additional children, please contact us. 2. Parents Information Mothers Info: Full Name Phone Number Area Code Phone Number Address Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country E-mail Primary email Marital Status MarriedSingleDivorcedSeparated Religion Jewish by birthJewish by conversionNot Jewish Fathers Info: Full Name Phone Number Area Code Phone Number Address Leave blank if same as above Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country E-mail Primary email Marital Status MarriedSingleDivorcedSeparated Religion Jewish by birthJewish by conversionNot Jewish Child may be picked up from camp by: Name and Relationship I would like to receive news and updates by email 3. Emergency Information Emergency Contact First Name Last Name Phone Number Area Code Phone Number Relationship I hereby give consent to the administration of Chabad Winter Camp to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I understand that, when possible, every effort will be made to contact parent/guardian or emergency contact before Chabad Winter Camp will undertake such a decision. Signature of Parent or Guardian Date & Time Month Day Year at 123456789101112 Hour001020304050 MinutesAMPM 4. Payment InformationA $50 non-refundable registration fee per child applies as part of this registration. Total $0.00 I would like to pay today:Full amount20% minimum: $0.00 $ Yes, I'd like to donate the cost of processing this transaction by adding 3.5% Agreement* I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid. I give Gan Israel permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit. General comments 5. Terms and Conditions PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Chabad Winter Camp (CWC) both on and off site, trips, transportation to and from trips etc., unless I advise you otherwise in writing. Limited Guardianship Approval: I hereby consent that CWC's directors - Rabbi Israel & Mrs. Tzipora Labkowski be granted limited guardianship capabilities with regards to signing waivers on behalf of my child / children for trips specified in this year's camp schedule. (I do understand that I may still be asked to fill out waivers, as not all locations accept this consent) PAYMENT AND CANCELATION: Payment terms are a $50.00 non-refundable deposit per camper to accompany registration. The balance is due by Dec. 22, and is non-refundable after that date. 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 fellow campers or who violates camp rules and regulations. In the event of dismissal, tuition will be refunded on a prorated basis less the $50.00 registration deposit. 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. INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless Chabad Winter Camp (CWC) and its officers, servants or assignees from any liability concerning our child’s involvement in CWC and further agree that the use of any premises during the CWC camp day is made at the risk of the registrant. I have read and agree to all of the terms and conditions in this Application Form. I am including a non-refundable $50 registration deposit per camper along with submission of this form. I further agree to remit the full tuition and any other fees by Dec. 22 as per the agreed timeline of my choice on this form. Signature of Parent or Guardian Date & Time Month Day Year at 123456789101112 Hour001020304050 MinutesAMPM Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearBilling Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Should be Empty: Submit This page uses TLS encryption to keep your data secure.
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