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2023 Shabbaton Application


February 17-19, 2023
Camp Bob Waldorf


Camper Information

as of February 17, 2023

Friend's Name

Friend's Name







SHABBATON MEDICAL FORM







PRESCRIPTION MEDICATIONS

NON-PRESCRIPTION MEDICATIONS*

All prescription and non-prescription medications will be stored with and administered by the camp nurse. The nurse may have a limited supply of acetaminophen, ibuprofen, diphenhydramine (Benedryl), cough drops/syrup, and/or antacids. Please initial here if you give permission to the camp nurse to administer non-prescription medications to your child, in the appropriate circumstance.

*YOUR CHILD WILL NOT BE GIVEN NON-PRESCRIPTION MEDICATIONS WITHOUT YOUR INITIALS.

Monthly payment plan available

If you are only registering one child, please skip to the Parent Information section.

Camper 2 Information

as of February 17, 2023

Friend's Name

Friend's Name







SHABBATON MEDICAL FORM







PRESCRIPTION MEDICATIONS

NON-PRESCRIPTION MEDICATIONS*

All prescription and non-prescription medications will be stored with and administered by the camp nurse. The nurse may have a limited supply of acetaminophen, ibuprofen, diphenhydramine (Benedryl), cough drops/syrup, and/or antacids. Please initial here if you give permission to the camp nurse to administer non-prescription medications to your child, in the appropriate circumstance.

*YOUR CHILD WILL NOT BE GIVEN NON-PRESCRIPTION MEDICATIONS WITHOUT YOUR INITIALS.

Monthly payment plan available

Parent Information

Both Parents
Mother
Father
Other

Name & Relationship to child

Permission Form

• The applicant agrees not to hold the Jewish Federation, my child’s synagogue, or Camp Bob Waldorf liable or responsible for any illness, injury, loss or damage related to their child(ren) attending and participating in the Shabbaton.

• I and my campers(s) agree to abide by all currently recommended COVID-19 policies and regulations of the Jewish Federation and Camp Bob Waldorf.

• Due to the ongoing COVID-19 pandemic, I understand that the Jewish Federation may be forced to cancel the Shabbaton based on recommendations by any federal, state, county, and local health and safety guidelines concerning overnight camp programs in force at the time. In the event that the Shabbaton is cancelled, a full refund will be issued.

• I consent to minor first aid and administration of medication for my child under the supervision of the camp nurse.

• The undersigned consents to the use of the camper’s name, photograph, or other identification in connection with the Jewish Federation’s programs, exchanges or publicity.

Child's Name

• I consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of a licensed hospital, whether such examination, diagnosis or treatment is rendered at the office of said physician or at such hospital.

• If I selected payment option 2, in lieu of the full financial payment, I understand that I have pledged that my child will perform 4 hours of community service for any nonprofit in our community by the end of the school year

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.
Total:   

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