Ezra Inter Girls Winter Camp 2020
Years 7 - 10

Sleep-away Camp:
19 - 23 Feb
Location Colchester (Essex Outdoor Centre)

IF YOU COMPLETE THIS FORM AND THEN DECIDE YOUR DAUGHTER WILL NOT BE ATTENDING CAMP PLEASE EMAIL ADMIN@EZRAYOUTH.COM TO LET US KNOW.

Please fill in this form and send payment by online transfer within 2 days of your application to reserve a place. If payment is not received within 2 days, we may not be able to keep your place.

THE FULL PRICE OF WINTER CAMP IS NOW £255, leaving from and returning to PAI House, NW11
All Chanichot will need to meet and be collected from PAI House. There is no group transport to and from Manchester.
Applications received after 10 Feb will incur a £30 late admin fee.

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
Jewish name *
Your answer
Surname *
Your answer
Age *
Your answer
Date of Birth *
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DD
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Name of School *
Your answer
School Year *
Home Address *
Your answer
Post Code *
Your answer
Home Phone Number *
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 daughter is able to swim *
GP Name and Number *
Your answer
I would like to book for Ezra Winter Camp for Girls and agree to make payment within 2 days of my application. I understand that if payment is not received I may lose my booking. *
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, WCG e.g. NameNameWCG
Required
I give my permission, and my daughter aged over 12 gives permission, for Ezra Youth Movement to take pictures of my child / herself 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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