Ezra Inter Boys Winter Camp 2019 / 20
Years 7 - 10

Sleep-away Camp:
29 Dec - 5 Jan
Location Colchester

Please fill in this form and send payment by online transfer to reserve a place on Ezra Winter Camp 2019.

THE FULL PRICE OF WINTER CAMP IS £299, leaving from and returning to PAI House, NW11
All Chanichim will need to meet and be collected from PAI House. There is no group transport to and from Manchester.
Applications received after 10 Dec will incur a £30 late admin fee.

If you would like to order a camp jumper at the cost of £10 please indicate below. Payment should be made with camp payment.

We will send out acceptance emails at a later date to all successful applicants.
Ezra UK reserves the right to refuse any application at their discretion.
First Name *
Your answer
Surname *
Your answer
Age *
Your answer
Date of Birth *
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Name of School *
Your answer
School Year *
Home Address *
Your answer
Post Code *
Your answer
Home Phone Number *
Your answer
Chanich Mobile Phone Number
Your answer
Chanich Email Address *
Your answer
Parent name *
Your answer
Parent email address *
Your answer
Parent contact number *
Your answer
Alternative emergency contact number *
Your answer
Name of reference (Teacher or Family Rabbi) *
Your answer
Contact number of reference (Teacher or Family Rabbi) *
Your answer
My child has asthma *
Required
My child has the following allergies: *
If your child has any allergies / asthma please provide further details below
Your answer
When was the last time your child had a tetanus injection? *
Your answer
Any prescribed medicines / painkillers must be handed in at departure in a clearly labelled ziploc bag. Please outline which medications your child takes, how often they should be given, and dosage.
Your answer
If your child requires non-prescribed medication whilst on camp, would you be happy for Ezra to provide them with paracetamol, plasters, savlon, Antihistamine, Immodium or Ibruprofen? *
Does your child have any of the following conditions or a history of:- Special Educational Need (e.g. Autism, Aspergers, ADHD, dyslexia); Mental Health condition (e.g. Eating Disorder, Self-Harm, Depression, Anxiety, Panic Attacks, Bipolar); Medical condition (e.g. Diabetes, Heart condition, IBS, Epilepsy, Asthma); Physical condition (e.g. Hypermobility, broken limbs); Behavioural issues *
If your child has received counselling/therapeutic support for something within the past 2 years please provide: Name and address of counsellor, The amount of time your child was in counselling, Date of last consultation (please write ongoing if it hasn’t finished)
Your answer
Please tell us if there is anything that would be helpful to know e.g. homesickness, enuresis, confidence issues, recent bereavement, family member with a serious illness or any other medical condition.
Your answer
My son is able to swim *
I have no objections to my child swimming under supervision. *
GP Name and Number *
Your answer
I would like to book for Ezra Winter Camp for BOYS. Payment will be made by 10 Dec. Applications received after this will incurr a £30 late admin fee. *
Please pay by online transfer, the details are: Account Name: Ezra Youth Movement, Account Number:00006407, Sort Code:30 93 50. Please use reference code first name, surname, WCB e.g. NameNameWCB
Required
I would like to order a camp jumper at the cost of £10 I will settle payment by 10 Dec 2019. Please indicate size required below. *
Please pay by online transfer, the details are: Account Name: Ezra Youth Movement, Account Number:00006407, Sort Code:30 93 50. Please use reference code first name, surname, WCB e.g. NameNameWCB
I give my permission, and my son aged over 12 gives permission, for Ezra Youth Movement to take pictures of my child / himself during this trip to use for promotional purposes. *
My signature below confirms agreement with the following statement: I am the parent/guardian of the above mentioned participant. Should the occasion arise, I give my consent to any emergency treatment necessary. I therefore authorize the group leader(s) to sign on my behalf, any written form or consent for medical treatment,provided that in the opinion of the Doctor or Surgeon concerned, any delay in obtaining my signature could endanger health or safety. *
Required
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