Camp Simcha 2021 - Form - Beth Torah Benny Rok Campus

Camp Simcha 2021
20350 NE 26th Avenue, Miami, FL, 33180
June 14th to August 6th
Infants to Entering 2nd Grade
Camp Hours
9 am to 3 pm
Morning Carpool - 8:40 am to 9:00 am
Afternoon Carpool - 3:00 pm to 3:30 pm
Half Day Pick Up - Noon

CAMPERS FOR SUMMER FRIENDS FOREVER

Session 1 - June 14th to July 9th
Session 2 - July 12th to August 6th
6 Week Session - June 14th - July 23rd

Camp Simcha Fees as of 2021
	4 weeks member/non-member	6 weeks member/non-member	8 weeks member/non-member
Pre Toddler	$1600 / $2000	$2000 / $2400	$2450 / $2900
Toddlers & 2's Half Day	$1550 / $1900	$1925 / $2250	$2300 / $2600
Toddlers & 2's Full Day	$1600 / $2000	$2150 / $2550	$2550 / $2900
3's Half Day	$1550 / $1900	$1925 / $2250	$2300 / $2700
3's full day	$1600 / $2000	$2100/ $2500	$2450 / $2800
Junior K	$1600 / $2000	$2100/ $2500	$2450 / $2800
Kindergarten Connection	$1600 / $2000	$2100/ $2500	$2550 / $2900
Senior Division	$1600 / $2000	$2100/ $2500	$2550 / $2900

All camp payments will be set up on a monthly payment plan ending May 15, 2021, unless the accounting office is notified via email (cabello@btbrc.org). Number of payments is dependent upon when registration form is received. Under no circumstances will payments be extended beyond May 15, 2021. Tuition Payments will be scheduled to begin at time of registration. The card used for registration will be the card used to set up your payment plan.

* Please Intial Here

PARENT/GUARDIAN # 1

Parent/Guardian # 1 Title

* Parent/Guardian # 1 First Name

* Parent/Guardian # 1 Last Name

* Parent/Guardian # 1 Address

* Parent/Guardian # 1 City

* Parent/Guardian # 1 State

* Parent/Guardian # 1 Zip

* Parent/Guardian # 1 Cell Phone

Parent/Guardian # 1 Work Phone

* Parent/Guardian # 1 E-mail

PARENT/GUARDIAN # 2

Parent/Guardian # 2 Title

Parent/Guardian # 2 First Name

Parent/Guardian # 2 Last Name

Parent/Guardian # 2 Address

Parent/Guardian # 2 City

Parent/Guardian # 2 State

Parent/Guardian # 2 Zip

Parent/Guardian # 2 Cell Phone

Parent/Guardian # 2 Work Phone

Parent/Guardian # 2 E-mail

* How many campers are you registering?

Total

* Student # 1 First Name

* Student # 1 Last Name

* Student # 1 Date of Birth

* Student # 1 Grade Level as of September 2021

* Student # 1 T Shirt Size

* Student # 1 Gender

* Student # 1 lives with

* If Other, Please Explain

* If you have selected the weekly option how many weeks will your child be attending?

Please list up to three children that you would like your child to be grouped with
(request are not guaranteed)

First Name

Last Name

First Name

Last Name

First Name

Last Name

MEDICAL INFORMATION

Student is allergic to

Treated with

Reaction

List Any Medications Your Child is Taking

* Student # 2 First Name

* Student # 2 Last Name

* Student # 2 Date of Birth

* Student # 2 Grade Level as of September 2021

* Student # 2 T-Shirt Size

* Student # 2 Gender

* Student # 2 lives with

* If Other, Please Explain

* If you have selected the weekly option how many weeks will your child be attending?

Please list up to three children that you would like your child to be grouped with
(request are not guaranteed)

First Name

Last Name

First Name

Last Name

First Name

Last Name

MEDICAL INFORMATION

Student is allergic to

Treated with

Reaction

List Any Medications Your Child is Taking

* Student # 3 First Name

* Student # 3 Last Name

* Student # 3 Date of Birth

* Student # 3 Grade Level as of September 2021

* Student # 3 T Shirt Size

* Student # 3 Gender

* Student # 3 lives with

* If Other, Please Explain

* If you have selected the weekly option how many weeks will your child be attending?

Please list up to three children that you would like your child to be grouped with
(request are not guaranteed)

First Name

Last Name

First Name Child 2

Last Name Child 2

First Name Child 3

Last Name Child 3

MEDICAL INFORMATION

* Student is allergic to

Treated with

Reaction

List Any Medications Your Child is Taking

EMERGENCY CONTACT #1

* Emergency Contact # 1 Full Name

* Emergency Contact # 1 Relationship

* Emergency Contact # 1 Cell Phone

* Emergency Contact # 1 Alt. Phone Number

* Emergency Contact # 1 E-mail Address

EMERGENCY CONTACT #2

* Emergency Contact # 2 Full Name

* Emergency Contact # 2 Relationship

* Emergency Contact # 2 Cell Phone

* Emergency Contact # 2 Alt. Phone Number

* Emergency Contact # 2 E-mail Address

Individuals Who Can Pick Up Camper

First Name

Last Name

Relationship

First Name

Last Name

Relationship

First Name

Last Name

Relationship

Individuals Who Can NOT Pick Up Camper

First Name

Last Name

Relationship

First Name

Last Name

Relationship

First Name

Last Name

Relationship

MEDICAL RELEASE

* Please Type Name of Parent/Guardian to Sign

I declare that I have provided Beth Torah Adath Yeshurun Inc, DBA Camp Simcha with all information regarding my child(ren)'s health, which may reasonably be needed to meet the medical and/or physical needs of my child(ren). I further agree that I can be reached at the telephone number(s) I have provided during the hours my child(ren) is/are at Camp Simcha. If an emergency arises, and none of the above numbers can be contacted for any reason, I hereby authorize Beth Torah Adath Yeshurun Inc, DBA Camp Simcha to seek emergency medical treatment administered by, but not restricted to, paramedics, hospital emergency room employees, and/or other medical professionals as reasonably necessary for the emergency medical treatment of my child(ren). I hereby release Beth Torah Adath Yeshurun Inc, DBA Camp Simcha and its staff members from any liability resulting from any medical services provided and agree to pay for such services upon invoice. I understand that the resulting expenses will be my responsibility and not the responsibility of Beth Torah Adath Yeshurun Inc, DBA Camp Simcha.

PHOTO RELEASE

* Name of Child/Children

* Please Type Name of Parent/Guardian to Sign

I agree to allow my child’s name, photograph, and information to be used by Camp Simcha in the programs' publications, videos, promotional materials social media and website, without compensation and without prior notice. I release and hold the school harmless from any liability stemming from the use of my child’s name, photograph, or information.

RECORDS RELEASE

* Name of Child/Children

* Please Type Name of Parent/Guardian to Sign

I agree to allow my child’s name, photograph, and information to be used by the school in Camp Simcha publications, videos, promotional materials social media and website, without compensation and without prior notice. I release and hold the school harmless from any liability stemming from the use of my child’s name, photograph, or information.

CAMP SIMCHA POLICIES

SHIRLEY SCHREIBER FAMILY CAMP SIMCHA POLICIES

Registration:

A $250 non-refundable registration and security fee per camper are required to register.
All enrollments are subject to space availability.
All placement requests MUST be included on the registration form. We will attempt to accommodate one request per camper.
A 10% sibling discount is applied and deducted from the lower camp fee.
Payment plans can be set up through May 15, 2021. Final payment of camp fees is due no later than May 15, 2021. If tuition is not paid in full by this day, a child's space is not guaranteed.
Any registration received after May 15, 2021 requires payment in full.
All health forms must be submitted to the camp office and be current to begin camp.

Refund & Cancellation Policy:

All refunds will be subject to a $100 processing fee and a $250 non-refundable registration fee per child, for a total of $350.
Camp fees are NON-REFUNDABLE after May 15, 2021, including, but not limited to absences, withdrawals, inclement weather, or in the event a camper is asked to leave camp for behavioral and/or disciplinary reasons.

Accident Form/Medications:

All allergies must be clearly noted in the health section of the registration form.
The health history provided to the camp is correct as far as I know, and the child that I have registered has permission to engage in all camp activities, except as noted by the examining physician or myself.
BTBRC/Camp Simcha does not assume responsibility for any injury. In case of a medical emergency, BTBRC/Camp Simcha has permission to take my child to the doctor/hospital to secure proper treatment. Parent/guardian assumes responsibility for all fees.

General Policies:

BTBRC/Camp Simcha is not responsible for lost or stolen items.
I grant BTBRC/Camp Simcha permission to use my child's photograph in promotional materials. I agree that neither my child, our assignees, nor myself will be entitled to compensation for such use.
I agree to pay the fees for the program in which my child is registered, including registration, security and safety, and late fees, where applicable. I understand that if my camp balance is not paid in full by May 15th, 2021, I will forfeit my reserved space with Camp Simcha and all monies paid.
I hereby give permission for my child to participate in all camp activities, including PG movies.
My child and I are aware that rules are established both before and during the summer, which enable us to provide a safe and secure environment for all. Any rules not followed may result in disciplinary action, up to and including dismissal from camp.
I understand that the activities in which my child participates during the course of camp may result in media coverage. I agree that my child's image, name, age and quotes may appear in such publicity.
All campers ages three and older must be potty trained.
MEMBERSHIP RATES WILL BE BASED ON MEMBERSHIP FOR THE FISCAL YEAR THAT BEGINS ON JULY 1, 2021. IF MEMBERSHIP IS NOT MAINTAINED THROUGH THE JULY 1, 2021-2022 YEAR, AN ADJUSTMENT TO TUITION WILL BE BILLED.

Food Policies:

All lunches and snacks served at camp are kosher.
We are a peanut and tree nut sensitive campus.
All snacks brought from home MUST be pareve, and peanut and tree nut free.
If celebrating a birthday, all goods brought onto campus MUST be kosher and adhere to that day's lunch (i.e. Dairy or Pareve on a Meat Day).

* Please initial below that you have read the Beth Torah Adath Yeshrun Inc. - Camp Simcha, and I understand and agree to comply with all of the conditions stated herein.

Grand Total