Yesh Summer Camp 2015 Application Form

VERY IMPORTANT – PLEASE NOTE:
. The information required in this form is of critical importance to the organizers and persons running Yesh for both the camps & activities throughout the year. All the information herein contained is for your child’s own benefit & should be completed meticulously & with care.
. The failure to supply all relevant and accurate information could have serious consequences for your child and other members of Yesh Camp SA.
. This application form applies to the camps and all activities run by Yesh Camp SA throughout the year, of whatsoever nature or kind.
. Incomplete forms or forms altered in any manner or way are unacceptable and will be rejected, preventing the organizers from accepting your child to the camps or any activities.
All information herein contained will be kept confidential.
Particular's of Camper
Please enter your FIRST NAME *
Your answer
Please enter your LAST NAME *
Your answer
Please enter your HEBREW NAME
Your answer
Please enter your HOME NUMBER
Your answer
Please enter your CELL NUMBER
Your answer
Please enter EMAIL ADDRESS at which we can contact you *
Your answer
Please enter your DATE OF BIRTH *
MM
/
DD
/
YYYY
Please enter your HOME ADDRESS *
Your answer
Please enter your SCHOOL, if not in school fill in N/A *
Your answer
Please enter your GRADE *
If not in school, please fill in relevant information in other
Please enter your ID NUMBER
Your answer
PARTICULARS OF CAMPER’S PARENTS
FATHER'S NAME *
Your answer
FATHER'S OCCUPATION *
Your answer
FATHER'S WORK ADDRESS *
Your answer
FATHER'S CELL *
Your answer
FATHER'S WORK NUMBER *
Your answer
FATHER'S EMAIL *
Your answer
MOTHER'S NAME *
Your answer
MOTHER'S OCCUPATION *
Your answer
MOTHER'S WORK ADDRESS
Your answer
MOTHER'S CELL *
Your answer
MOTHER'S WORK NUMBER *
Your answer
MOTHER'S HOME NUMBER *
Your answer
MOTHER'S EMAIL *
Your answer
3rd Party Contact Name *
Your answer
3rd Party Contact Relationship *
Your answer
3rd Party Contact CELL *
Your answer
3rd Party Contact HOME *
Your answer
REFERENCES
List two references. Preferably, include your Rabbi and a teacher or principal.
REFERENCE ONE NAME *
Your answer
REFERENCE ONE CELL NUMBER *
Your answer
REFERENCE TWO'S NAME *
Your answer
REFERENCE TWO'S CELL NUMBER *
Your answer
MEDICAL INFORMATION
NB: PLEASE REMEMBER TO ALSO EMAIL A COPY OF BOTH SIDES OF YOUR MEDICAL AID CARD TO forms@yeshcampsa.co.za IN ADDITION TO FILLING IN THE DETAILS BELOW
Name of Medical Aid *
Your answer
MEMBERSHIP NUMBER *
Your answer
MAIN MEMBER NAME *
Your answer
MAIN MEMBER'S DATE OF BIRTH *
MM
/
DD
/
YYYY
Applicants dependent number on card *
Your answer
Medical Aid Tel *
Your answer
FAMILY DOCTOR
Name of Family Doctor​​ *
Your answer
Dr Cell number *
Your answer
Dr Office number *
Your answer
Dr Home Number
Your answer
NUMBER of years with Family Dr​
Your answer
Name of Specialist attending to camper
Leave blank if it does not apply
Your answer
For what condition
Leave blank if it does not apply
Your answer
Specialist's office number
Leave blank if it does not apply
Your answer
Specialist's cell number
Leave blank if it does not apply
Your answer
MEDICAL HISTORY
Does the applicant suffer from any chronic illnesses? *
Please tick ANY and ALL appropriate boxes
Required
MEDICAL HISTORY DETAILS
For the following questions, please fill in the details in the box provided if the answer is 'Yes'.
If the answer is no, then move on to the next question.
Does the camper wear glasses / contact lenses? *
​If yes please ensure to supply SPARES and state prescription in the box below
Your answer
Does the camper have any prostheses?
Your answer
Has the camper ever been stung by a bee?​ *
If the answer is yes please state detailed reaction in the box below
Your answer
Is the camper a competent swimmer? *
Is there any reason why the camper shouldn’t participate in strenuous hikes?​ *
Please give reasons
Your answer
Does the applicant have any special dietary requirements?​ *
If the answer is yes please give details in the box below
Your answer
Has the applicant ever been hospitalized?​ *
Please state why
Your answer
​Does the applicant have any emotional, psychological or psychiatric problems​? *
Please give details
Your answer
When last did the applicant have an anti-tetanus injection?​​ *
(If not given within the past 5 years, please ensure an injection is administered prior to camp)
MM
/
DD
/
YYYY
MEDICATION
If the applicant is taking medication regularly, please answer the next section.

1. Name of medication​
2. Time and dosage daily​
3. Doctor Prescribing medication​
4. Date when medication was recently prescribed
Medication Details:
Your answer
ALLERGIES
If the applicant has any genuine allergies, please provide full details and medication necessary. Please ensure that this medication is sent - with the applicant to camp as well as a spare for care of the camp director - correctly labeled with:
a) Applicants name, b) Dosage, c) Allergies to etc.

Also state:
a) whether the applicant carries other medicine such as an “epipen” etc,
b) if the applicant has ever needed a cortisone injection for the allergy.
Medication Details:
Your answer
​THE CAMP ORGANIZERS RESERVE THE RIGHT TO CALL FOR A MEDICAL CERTIFICATE FROM THE FAMILY DOCTOR REFERRED TO ABOVE OR A MEDICAL PRACTITIONER OF THEIR CHOICE, TO CLARIFY ANY OF THE INFORMATION PROVIDED HEREIN.
Payment Arrangements
Please note:
NO CHECKS ACCEPTED!
CASH PAYMENT BY ARRANGEMENT ONLY
EFT'S ONLY

Banking Details:
Bank Name: Standard Bank
Account Name: Yesh Camp SA
Account Number: 201652951
Branch: Norwood
Branch Code: 004105

For reference use INITIALS followed by SURNAME and WINTER15
e.g. V BOKOW WINTER15
Please select the personally appropriate financial arrangement:
Should you need an alternative reduction or a subsidy, please advise what you can afford and in how many installments
Your answer
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