Summer Camp

Thank you for your interest in HDC’s Summer Camp! To register, please fill out the form below.

For any questions, please contact Leah at labergel@hdconline.org or (888) 753-8100

Child's Name (required)

Gender
 Male Female

Child's Address

Date of Birth

Synagogue Affiliation

Do you have any other children in the program?
 Yes No

Sibling's Name

How did you hear about Camp Hdc?
 Friend Newspaper Ad Web Referred by HDC Family

PARENTAL INFORMATION

Father's Name
Father's Religious Affiliation

Mother's Name
Mother's Religious Affiliation

Is there any religious conversion in the family?
 Yes No

Home Phone # Father's Cell #
Mother's Cell # Father's Work #
Mother's Work #

Father's Occupation: Mother's Occupation:

Parent's Marital Status  Married Separated Divorced Widow(er)

Father's Email Mother's Email

HEALTH/LIABILITY FORM

Pediatrician's Name Pediatrician's Phone

Does your child have any problems with the following:

Diabetes Yes No

Food Allergies  Yes No

Allergies to Medication  Yes No

Low Blood Pressure  Yes No

High Blood Pressure  Yes No

Hearing Loss  Yes No

Heart Problems  Yes No

Seizures  Yes No

Respiratory Problems  Yes No

Does your child have any other serious problems/been under a physician's care recently?
 Yes No If yes, please explain

Is there any other existing medical conditions of special concern (including allergies to medication)?
 Yes No If yes, please explain

Emergency Contact

Name Relationship

Contact Phone #:

Name Relationship

Contact Phone #:

I hereby give permission to my child to participate in all HDC programs, activities and events and do release HDC and its representatives from all liability arising out of my child's participation in such activity. In addition, I, undersigned parent/guardian of the above child, do further certify that my child is physically able to participate in such activity and hereby authorize HDC and its authorized representative as agents for the undersigned, to consent to any x-ray examinations, anesthetic, medical or surgical diagnosis or treatment and hospital care which is to be rendered under the general or specific supervision of any licensed physician (under the provision of the California Medicine Practice Act) or the staff of a licensed hospital, whether such diagnosis, examination or treatment is rendered at the office of said physician, or at such hospital. It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment or hospital care being required, and is given to provide authority and power on the part of our above named agents to give specific consent to any and all such examinations, diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgement may deem advisable. The authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

Please checkmark for acceptance:

I give authorization to the Hebrew Discovery Center staff members to administer medication to my child when necessaary. Any prescription medication, such as, but not limited to: Tylenol, Motrin, Benadryl, etc. will be provided by the parent and administered by the facility director. Any medication given will be recorded in a log with date, time and amount administered, a copy of this record will be provided to the parents. **This form must be completed as well as a signed note each time indicating the request of the parent to administer medication, reason, as well as duration of time.

I give authorization for my child's photography or likeness to be utilized in HDC promotional materials. All digital media will be stored on file at HDC.

I give permission to HDC staff members to apply sunscreen to my child at their own discretion.

I have read and understand and fully agree to the above medical/liability statements

Enter name for acceptance

Once completed, please process payment through Eventbrite if you have not done so already. Thank you!

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