Parent Name(s) *

Mother's Cell *

Father's Cell *

Mother's email *

Father's email *

Child's Name *

Child's Age *

Weeks Attending *
week 1 - 6/26 - 6/30week 2 - 7/3 - 7/7week 3 - 7/10 - 7/14week 4 - 7/17 - 7/21week 5 - 7/24 - 7/28week 6 - 7/31 - 8/4

Child's Doctor *

Child's Doctor's Phone # *

Medical Insurance Carrier *

Medical Insurance # *

Allergies *

Medications *

Other health concerns *

Is your child potty trained? *
YesNo

Child t-shirt size *

I give permission for my child(ren)’s counselors to administer emergency first aid to my child(ren) if needed, and to seek the assistance of medical professionals if the situation requires. I understand that Camp Yavneh will make every effort to contact me immediately if emergency first aid is administered. I understand that my child(ren) may not attend Camp Yavneh unless I give permission for emergency medical treatment.

I give permission for my child’s counselors to apply sunscreen to my child for the duration of camp. I understand that my child may not attend Camp Yavneh unless I give permission for sunscreen application.

I give permission for Camp Yavneh to take pictures of my child during camp, and to use those pictures for marketing purposes. I understand that my child’s image will never be connected with his or her name.

I give permission for my child to go on walking field trips in the Seward Park neighborhood. I understand that if I do not give permission my child may have to stay home on days when walking trips are planned. I understand that no refund will be given in such situations.

I give permission for my child to go on driving field trips. I understand that these field trips will be driven and chaperoned by parent volunteers, and I agree that I will provide a suitable booster or car seat on field trip days. I understand that my child will not be permitted to go on the field trip if I do not provide a booster or car seat. I understand that if I do not give permission for my child to go on field trips, my child will join the younger groupings on trip days.

I acknowledge that I am placing my child(ren) in Camp Yavneh, which is a service provided by BCMH. Each child may remain at Camp Yavneh at the sole discretion of the Camp Director. I further acknowledge that Camp Yavneh incorporates some vigorous physical activity and interaction with other children, and that such activities by their nature carry inherent risk of injury. I hereby certify that my child(ren) are fit, physically and otherwise, to participate fully in all activities at Camp Yavneh. In consideration of my being allowed to place my child(ren) in Camp Yavneh and intending to be legally bound, I hereby waive, release, hold harmless, covenant not-to-sue, and forever discharge any and all rights, actions or claims of negligence that I or my heirs, executors or assigns may have against Bikur Cholim – Machzikay Hadath, its officers, employees, agents, and leaders, for death, injury, loss and any and all damages that I or my child(ren) may sustain and/or suffer in connection with my child(ren)’s participation in Camp Yavneh. I also agree to indemnify BCMH for any defense, cost, or expense arising out of any claim of damages, injury, or death arising from my child(ren)’s participation in Camp Yavneh.

Additional emergency contacts if different from mother and father

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