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Camp Shalom Registration 2017
Please complete this form to register for Camp Shalom 2017. To complete registration please click on the PayPal link at the end of the form to make a payment or send/drop off a check at the Oak Park Temple office, 1235 N. Harlem, Oak Park IL 60302. Please write Camp Shalom in the memo field of the check.
Flash sale: register between April 26 and Friday April 28 at 5:00 for 10% discount
Camp Shalom weekly rates for summer 2017: OPT members $330 and non members $350 per week - Early drop off is $10 per day. ( Week of July 4 is pro rated for holiday). Camp Shalom tuition includes costs for field trips, swim lessons with bus service, snacks, Friday lunches and all other supplies and programs.
Camper Last name
Camper first name
Grade Level in Fall 2017
Please check each week of Camp Shalom registration:
June 12 - June 16 ($330 OPT members/$350 non-members)
June 19 - June 23 ($330 OPT members/$350 non-members)
June 26 - June 30 ($330 OPT members/$350 non-members)
July 3 - July 7 (no camp July 4) ($264 OPT members/$280 non-members)
July 10 - July 14 ($330 OPT members/$350 non-members)
July 17 - July 21 ($330 OPT members/$350 non-members)
July 24- July 28 ($330 OPT members/$350 non-members)
Home address, city, state zip code
Home phone number
Name of primary parent/guardian to contact first
Primary parent/guardian cell phone
Primary parent/guardian work phone
Primary parent/guardian e-mail
Name of second parent/guardian to contact
Second parent/guardian cell phone
Second parent/guardian work phone
Second parent/guardian e-mail
Do you require early drop off?
Early drop off is available at 7:45 am every day @ $10 per day
Please let us know which weeks or days you need early drop off. This can be changed or added during the summer.
Camp Shalom provides 7 hours of day camp. We provide snacks daily and lunch on Friday. We travel by school bus for swimming lessons four days per week and to a field trip location on the fifth day. Please provide complete medical information to keep your child safe and happy all day every day.
Please provide name and cell phone for an emergency contact (if you can't be reached)
Does this camper have any allergies? If yes, please tell us what the symptons of a reaction are and what to do in that situation.
Are there any medications we need to be aware of? Does your child have an inhaler or epipen in their backpack? Provide instructions for administration of any medication.
We strongly recommend campers taking medications to help with behavioral issues continue their daily dose when at Camp Shalom. It is a seven hour camp day full of social interaction, please help your child be successful! We can administer medication with your written permission.
Are there any other medical conditions, procedures or precautions that we need to know about? Are there any special needs or situations that will enhance your child's experience at camp? Please specify.
Is your child in compliance with the State of Illinois immunization requirements to attend school?
Please tell us about your child's swimming abilities. We will share this information with swim instructors AND use it for supervision during free swim field trips.
Does your child know how to swim?
yes, comfortable swimmer
swims a little, puts face in water
swims a little, doesn't put face in water
can't swim at all
Please add any information about swimming level here:
Who picks up your child after camp?
Please tell us who will be picking up your child. We will expect to see these people at pick up. If you have a change in plans just let either Robin or your child's counselor know before pickup time. If someone comes to pick up your camper who is not named here, and if you did not alert us to the change, we will ask to see identification from the adult and then call you to confirm the arrangement.
Who will pick up your camper? Provide all the names necessary.
Releases and Permission Forms
Camp Shalom travels to field trips and swimming lessons by school bus. Campers also walk short distances during outside playtime.By enrolling in Camp Shalom, I acknowledge that I have given permission for my child/children to participate in any field trips to destinations away from Oak Park Temple.
I give permission for my child to participate in field trips away from Oak Park Temple.
PERMISSION FOR EMERGENCY MEDICAL SERVICES
I AUTHORIZE Camp Shalom to obtain emergency medical aid for my child if necessary and I authorize treatment by the physician on call if I cannot be reached
I DO NOT authorize Camp Shalom to obtain medical aid for my child if necessary in absence of my approval
Release of All Claims I am the parent or guardian of the minor whom I enrolled in Camp Shalom. I understand and acknowledge that there can be dangers and risks of injury to my child while going to, attending and returning from Camp Shalom. I know that my child will attend Camp Shalom at his or her own risk. In consideration for the payment of fees and the permission for my child to attend Camp Shalom, and for other consideration, I do hereby REMISE, RELEASE and FOREVER DISCHARGE Oak Park Temple B’nai Abraham Zion, Camp Shalom, and their agents, employees, officers, successors and assigns, from any and all liability, claims or causes of action which I or my child may have against any of them arising from or growing out of any accident, casualty, occurrence or event in connection with my child’s attendance at Camp Shalom, or transportation to and from Camp Shalom. I also agree for myself and for my heirs, executors, administrators, successors and assigns, to defend, protect, indemnify and save harmless Oak Park Temple B’nai Abraham Zion and Camp Shalom, and their agents, employees, officers, successors and assigns, from any claims, damages or causes of action which may be made against any of them by or on behalf of my child, including the payment of the attorney’s fees and costs in the defense of any such proceeding. I HAVE READ THE ABOVE BEFORE I SIGNED IT. I UNDERSTAND IT. I INTEND TO BE BOUND BY IT. I ACKNOWLEDGE THAT THIS IS A FULL AND FINAL WAIVER AND RELEASE OF ANY AND ALL CLAIMS FOR MYSELF AND MY CHILD WHOSE NAME IS LISTED ABOVE.
I have read this release of all claims and I agree to the terms described in it.
I grant to Camp Shalom at Oak Park Temple, its representatives and employees, the right to take photographs of my child while attending Camp Shalom at Oak Park Temple, Camp Shalom events, and Oak Park Temple events. I authorize Camp Shalom at Oak Park Temple to use and publish photos in print and/or electronically. I agree that Camp Shalom at Oak Park Temple may use such photographs of my child without their name for any lawful purpose, including for such purposes as publicity, illustration, advertising, and Web content.
Yes - photography release
No - photography release
Please calculate the total tuition based on the weekly rates listed above plus early drop off. 10% discount applies to all fees paid in full by April 1st.
Total payment due
Calculate the total amount you owe:
How will you submit 25% deposit (or full tuition)?
Registration is NOT complete until deposit is received!
Check sent to Oak Park Temple, 1235 N. Harlem, Oak Park IL 60302
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