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Camp Gems - Holiday Program

CAMP GEMS ENROLMENT FORM. 7 July 2021

PLEASE READ BEFORE REGISTERING - Covid-19, Limited Space. Camp Gems Winter 2021 is subject to Covid-19 Restrictions & Weather. In the event of a rain forecast, we will unfortunately cancel that day of camp. In usual circumstances backup trips are planned for a last-minute rainy day. However, due to venue capacity limits (due to covid-19 restrictions), venues will not hold space nor will a last minute change of trip be guaranteed. If camp does not go ahead that day, a full refund will be sent that day. If you are relying on camp Gems for child care, please reconsider or arrange a backup plan in the event of rain. Thank you for your understanding.
To view camp details and trip program please click here , or go to www.cgems.org.au/campgems
Child 1 Information
Child 1

First Name Nickname Last Name
C1. Birth Date

DD/MM/YYYY
C1. Gender

Male Female
C1. Grade
C1. School
C1. Tetanus to date

Yes No
C1. Any Medical Conditions?
C1. Food or Drug Allergies
C1. Does your child have an EPIPEN

If Yes, please bring it on the day and hand it DIRECTLY to the Director (Moshe).
C1. My child would like to be in the same group as:
C1. Register days 7 and 8 July 2021

Wednesday
Child 2 Information
Child 2

First Name Nickname Last Name
C.2 Birth Date

DD/MM/YYYY
C2. Gender

Male Female
C2. Grade
C2. School
C2. Tetanus to date

Yes No
C2. Any Medical Conditions?
C2. Food or Drug Allergies
C2. Does your child have an EPIPEN

If Yes, please bring it on the day and hand it DIRECTLY to the Director (Moshe).
C2. My child would like to be in the same group as:
C2. Register days 7 and 8 July 2021

Wednesday
Child 3 Information
Child 3

First Name Nickname Last Name
C3. Birth Date

DD/MM/YYYY
C3. Gender

Male Female
C3. Grade
C3. School
C3. Tetanus to date

Yes No
C3. Any Medical Conditions?
C3. Food or Drug Allergies
C3. Does your child have an EPIPEN

If Yes, please bring it on the day and hand it DIRECTLY to the Director (Moshe).
C3. My child would like to be in the same group as:
C3. Register days 7 and 8 July 2021

Wednesday
Parents and Contact Information
Mothers Name

First Name Last Name
Mothers Mobile
Mothers Home Phone
Mothers Email
Fathers Name

First Name Last Name
Fathers Mobile
Fathers Home Phone
Fathers E-mail

Address Child's Primary Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Marital Status

For mailing titles and sensitivity
Is the natural Mother of the children Jewish

Yes No
If there are any conversions in the family please provide details.
Shul Affiliation & name if any
Emergency Information
Emergency Name

First Name Last Name
Relationship to child
Emg Mobile
Emg Home Phone
Local GP Name and Number
Anything else you would like us to know
How did you hear about us
Please send me info on Gems Hebrew School

Yes Please No Thanks
DECLARATION OF PARENT / GUARDIAN
I hereby authorise GEMS - Chabad House Glen Eira leaders and staff to obtain any medical care necessary for my child. I understand that in the case of emergency of any significant illness or injury, attempt will be made to contact myself when practical. I agree to pay for any cost that may occur as a result of the injury/illness. I acknowledge my child may be participate in activities within and outside the Chabad grounds. I authorise my child to participate in these activities.
I hereby authorise GEMS - Chabad House Glen Eira to photograph my child and to use the photographs at their discretion.
I agree to the above declaration.

Yes, I agree
Full Name*

First Name Last Name

Payment

Credit Card

Credit Card Type
Credit Card Number
Name on Card
Expiration Month	Expiration Year

Total

$0.00
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CAMP GEMS ENROLMENT FORM. 7 July 2021

Child 1 Information

Child 2 Information

Child 3 Information

Parents and Contact Information

Emergency Information