Camp Ruach Lbanos Application

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CAMP INFO
CAMPER INFORMATION
PARENT INFORMATION
EMERGENCY & MEDICAL INFORMATION
Payment Information

Camper information

Camper's Last Name

Camper's First Name

Date of Birth

Present Grade

Which trip will you be attending?

School Attending

Current Teacher (Last Name Only)

Bunk Requests First Trip:

Bunk Requests Second Trip:

Does your daughter have any medical or physical issues, or allergies?

Please Explain:

Do you give camp permission to administer Tylenol or Benadryl?

MEDICAL FORMS: Due to new regulations, we are required to have a complete immunization records on file for each camper. Please email your medical record to [email protected]. All records will be kept strictly confidential.

Are you signing up for transportation?

Full Summer

First Half

Second Half

My school bus stop is:

If you live in a development, please specify:

IMPORTANT! This year we will not be able to accommodate last minute requests for bussing. You must sign up for bussing now. Thank you for your understanding.

Parent information

Last Name

Home Phone

Mother's Name

Mother's Cell

Receive Texts?

Yes No

Father's Name

Father's Cell

Receive Texts?

Yes No

Street Address

City

State

Zip

Emergency Contacts

Contact 1

Relationship

Emergency Phone

Contact 2

Relationship

Emergency Phone

Family Physician

Phone

CONDITIONS OF ENROLLMENT

This certifies that I release the directors of the camp and any staﬀ members from any claims of liability that may arise. I am aware that my daughter(s) will be going swimming in a supervised pool and will be traveling on trips and excursions as part of the camping program. I agree not to take any legal action against the camp. I have read and understood the cover letter.

Name:

Signature

Date

Payment Information

Total: $

Payment

Please Select Payment Method:

Credit Card (A 3% Fee Applies)

Check (There is no surcharge for ACH Debit Payments)

We accept all credit and debit card payments.

A $250 per camper per half, non-refundable registration fee must be submitted with your application. This will be applied towards your total.

Card Details

Amount

Name On Card

Zip Code

Card Number

Expiry Date

CVV

Early Bird price: $ $

A 3% processing fee will be added to all credit card payments.

Notes, Comments, and Suggestions

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Download Camp Application

Please Select Payment Method:

Payment Options:

Card Details

Check Details

Welcome to Camp Ruach Lbanos!