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2019 Shabbaton Application


March 1-3, 2019
At Alpine Meadows

Open to all students in grades 3rd through 9th
Living in the San Gabriel and Pomona Valleys


Camper Information

Male
Female

as of 03/19

(Please specify whether it's child size or adult size)

If you live outside the San Gabriel and Pomona Valleys please contact our office to obtain the application for those living outside our geographical service area; contact us at 626.445.0810 or federation@jewishsgpv.org

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

• I release Jewish Federation & my child’s school from all responsibilities other than housing, meals and supervised camp activities.

• 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: