Chabad Camp Catan promises a real adventure in a fun and nurturing space for tots to thrive socially, emotionally and spiritually. Chabad Camp Catan caters to children ages 2-4 from diverse Jewish backgrounds and affiliations through a stimulating camp experience. Camp runs from 9:30am-3:00pm, Monday through Friday from July 8th to August 16th 2024. Where did you hear about us? 1. Child’s Information Full Name* First Name Last Name Hebrew Name* Birth Date* Month Day Year Gender* Age on July 1* Sessions ($185 per session)* Week 1 - July 8-12Week 2 - July 15-19Week 3 - July 22-26Week 4 - July 29-August 2Week 5 - August 5-9Week 6 - August 12-16 (No camp on the 13th) Medical Information: Pediatrician First Name Last Name Phone Number Area Code Phone Number My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain* Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Are there any social or other challenges we should be aware of? 2. Parents Information Mothers Info: Full Name* Phone Number* Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country E-mail* Primary email Religion* Jewish by birthJewish by conversionNot Jewish Fathers Info: Full Name* Phone Number* Area Code Phone Number E-mail* Primary email Religion* Jewish by birthJewish by conversionNot Jewish Child may be picked up from camp by:* Name and Relationship I would like to receive news and updates by email 3. Emergency Information Emergency Contact* First Name Last Name Phone Number* Area Code Phone Number Relationship* I hereby give consent to the administration of Chabad Camp Catan to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I understand that, when possible, every effort will be made to contact parent/guardian or emergency contact before Chabad Camp Catan will undertake such a decision. 4. Payment Information Total $0.00 Yes, I'd like to donate the cost of processing this transaction by adding 3% Payment Credit Card Paypal I will contact Raizy at 561.412.8288 for a payment plan Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Expiration Year Paypal has been selected. Payment will take place on the next page. Billing Address Street Address City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country General comments 5. Terms and Conditions PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Chabad Camp Catan (CCC) unless I advise you otherwise in writing. IMAGES, ETC.: Permission is hereby given to use in promoting the Camp and in other ventures directly relating to the Camp (i) digital, photographic and video images or likenesses of camper; audio of camper; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by camper or originating from Camp or from a Camp-related activity. INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless Chabad Camp Catan (CCC) and its officers, servants or assignees from any liability concerning our child’s involvement in CCC and further agree that the use of any premises during the CCC camp day is made at the risk of the registrant. I have read and agree to all of the terms and conditions in this Application Form. Signature of Parent or Guardian Date & Time Month Day Year at 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM Should be Empty: Submit This page uses TLS encryption to keep your data secure.