MAKOM CAMP REGISTRATION 2015
       Welcome to Makom Camp.  We’re very excited for Camp and it promises to be amazing!  
       The week will be filled with creative activities and art projects, sports and games, and field trips to local 
       parks. It will be an exciting time for learning, making new friends, building community, and having fun!
       We have great, warm counsellors who will take good care of your child, lead activities, encourage your 
       child’s participation, and teach your child conversational Hebrew through speaking mostly in Hebrew.
       Makom Camp is open to all children entering JK to Grade 4. 
       Makom Camp will run August 31 to September 4 from 9am to 5pm daily.
       Pick up and drop off promptly in the lobby of the Miles Nadal JCC – 750 Spadina Ave.
       Fee: $250 per child for the week, payable in full upon registration
       Please send your child with a healthy, hearty lunch each day, along with morning and afternoon snacks.
       If you have any questions or concerns, please contact Jen Turack: jen@makomTO.org or 416-823-8950.
       INSTRUCTIONS FOR SUBMITTING REGISTRATION FORMS AND PAYMENT:
       Please submit all forms with applicable fees, payable to Makom, and mail to:
          Makom, 141 Markham St., Toronto, ON, M6J 2G4
       CHECKLIST - ENSURE YOU HAVE SUBMITTED THE FOLLOWING WITH YOUR APPLICATION:
       ___ Registration and Medical Consent Form (one per child)
       ___ Payment and Refund Policy Agreement (one per child)
       ___ Waiver and Permission Form (one per family)
       ___ Fee
        ___Additional Charitable Donation (optional)
                                          MAKOM CAMP REGISTRATION AND MEDICAL CONSENT FORM 2015
                      Camper: ___________________________________     Date of Birth: ___________________
                      Grade in September 2015: ___________________        Gender: ________________________
                      Hebrew Name (if known): ______________________________________      _________ ___
                      Parent(s):___________________________________________________________________
                      Home Phone:  _____________________________________________________   _________ 
                      Work Phone:  Parent 1                                                            Parent 2______                __________        
                      Cell Phone:   Parent 1                                                              Parent 2                       __________   _  
                      Email: Parent 1                                                                          Parent 2 _______________________
                      Mailing Address:_____________________________________________________________
                      Emergency Contacts (name, relationship to camper and cell phone number): 
                      1. ______________________________________________  
                      2. ______________________________________________     
                      3. ______________________________________________
                      Ontario Health Number: ____________________________
                      Family Doctor:  ________________                                            ___       Tel #                                ______________ 
                      Medical Conditions
                      Does your child have any significant medical conditions, physical limitations, or any other concerns that 
                      might affect her/his full participation in program activities?  Yes____   No____
                       If yes, please describe and provide details of usual treatment: 
                      _____________________________________________________________________________________
                      _____________________________________________________________________________________
                      Please explain if your child has any medical condition that requires any modification of his/her program: 
                      _____________________________________________________________________________________
                      _____________________________________________________________________________________
       Allergies/Asthma
       Please list all known confirmed allergies to the following:
       (a) Foods: ____________________________________________________________________________
          If foods are life-threatening, please explain the symptoms and the treatment: 
          ______________________________________________________________________________
       (b) Medications: _______________________________________________________________________
       (c) Other (e.g., bee or wasp stings, environmental allergies): ____________________________________
       Has your child suffered any serious allergic or asthmatic reaction? 
          If so, please provide details, including the type and severity of reaction: ____________________
          Is allergy considered: Mild____   Moderate____   Serious____   Life-Threatening ______
       Has a doctor prescribed an Epi-Pen for your child?  Yes____   No____
          (Prescribed epi-pens must be carried by the camper at all times)
       Has a doctor prescribed an inhaler for asthma?  Yes____   No____ 
          (Prescribed asthma inhalers must be carried by the camper at all times)
       Has a doctor prescribed an inhaler for any other reason?  Yes____   No____
          Please specify: __________________________________________________________________
       Dietary Restrictions
       Please list any foods your child should not eat for medical, dietary, or religious reasons: 
       _____________________________________________________________________________________
       Medication
       Does your child take prescribed medication on a regular basis? Please specify: _____________________
       _____________________________________________________________________________________
       General
       (1) Does your child wear or carry medical alert identification?  Yes____   No____
          If yes, please specify what is written on it: ____________________________________________
                          (2) Does your child have any other relevant medical condition that will require modification of the 
                          program?  Yes____   No____
                                      If yes, please explain: _____________________________________________________________
                          (3) Does your child have any special fears or conditions (e.g., anxiety, bed-wetting, and nightmares), the 
                          knowledge of which will allow the teacher to make her/his experience more relaxed?  Yes____   No____  
                                      If yes, please explain: _____________________________________________________________
                                      ______________________________________________________________________________
                          Should it become necessary for my child to have medical care, I hereby give the counsellor permission to
                          use her/his best judgment in obtaining the best of such service for my child.  I also understand that in 
                          the event of such illness or accident, I will be notified as soon as possible.
                          Name of Parent (please print):____________________________________________________________
                          Signature of Parent: ____________________________________________________________________
                          Date: _______________________
                          AUTHORIZED PERSONS FOR DROP OFF & PICK UP – PLEASE INCLUDE CELL PHONE NUMBERS
                          The following individuals are authorized to drop off or pick up my child from Makom Camp:
                          1. 
                          2.
                          3.
                          4.
                          5. 
                                                                  MAKOM CAMP PAYMENT and REFUND POLICIES
                          Makom Camp registration fee is $250 for the week and is fully non-refundable.
                          Full payment for each camper is due at time of registration.
                          Please make cheques payable to Makom and mail to 141 Markham St., Toronto, ON, M6J 2G4
                          Cheques returned as NSF are subject to a $40 fee per cheque.
                          I understand and accept Makom Camp Payment and Refund Policies.
                          _____________________________________________________________________________________
                          Parent’s Name (please print)
                          _____________________________________________                                                       ________________________________
                          Parent’s Signature                                                                                  Date