Ezra Mad GIRLS Summer Camp 2019
Year 12
Camp Venue: Llanarth, Wales
Dates: 13th - 26th August 2019
Cost: The full price of MAD Girls Summer Camp is £700.
This includes transport to and from camp from PAI House, NW11.

Please complete the form below and send a deposit of £200 by online transfer ONLY to reserve a place on Ezra Summer Camp 2019. A place will not be reserved unless a deposit is received within ONE week of receipt of application.

Applications made after 15th June 2019 will incur an additional £30 Admin fee

There is limited space on the camps. Sending in this form and transferring the payment does not mean you have been accepted on to the camp. You will receive an acceptance email at a later date. Ezra UK reserves the right to refuse any application if they decide the applicant is not suitable for the camp at any time before or during the camp.

Please see www.ezrayouth.com for further details.
If you have any questions please email camps@ezrayouth.com.
First Name *
Your answer
Surname *
Your answer
Age *
Your answer
Date of Birth *
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Nationality *
Your answer
School Year *
Name of School *
Your answer
Contact number of School *
Your answer
We reserve the right to discuss details of your child's application with the school. Please tick the box if you have any objections to us doing so
Home Address *
Your answer
Post Code *
Your answer
Country *
Your answer
Home Phone Number *
Your answer
Mobile Phone Number *
Your answer
Email address *
Your answer
Parent name *
Your answer
Parent email address *
All camp correspondence will be sent to this email.
Your answer
Parent email address 2
If you would like camp correspondence to be sent to a second email address as well please provide it here.
Your answer
Parent contact number *
Your answer
Name of Emergency contact 1 *
Your answer
Emergency contact number 1 *
Your answer
Name of Emergency contact 2 *
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Emergency contact number 2 *
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Medical Information / Allergies *
Please provide information of any medical conditions / allergies / dietary allergies or requirements
Your answer
Additional Medical Information *
If your child has any educational, behavioral or eating disorders or has had any counselling or therapy within the last 6 months please indicate below so that we can discuss further.
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GP Name and Number *
Your answer
Name of Shul *
Your answer
Name of Family Rabbi *
Your answer
Contact Number of Family Rabbi *
For reference
Your answer
Name and Contact Number of Teacher *
For reference
Your answer
I would like to book for Ezra Summer Camp MAD GIRLS 2019 *
All payments must be made by online bank transfer. Account Name: Ezra Youth Movement, Account Number:00006407, Sort Code:30 93 50. Please use reference first name, surname, reference code (SMG) e.g. NameNameSMG
I give permission for Ezra Youth Movement to take pictures of my child during this trip to use for promotional purposes. *
Please ask your daughter to tick below: I give permission for Ezra Youth Movement to take pictures of me during this trip to use for promotional purposes. *
I give my child permission to partake in this activity. I grant permission for any Madricha to take any necessary action should there be any unforeseen occurrences be it medical or other. *
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