Ezra Inter Girls Winter Camp 2022
WAITING LIST ONLY  WE WILL BE IN TOUCH IF A PLACE BECOMES AVAILABLE






Years 7 - 10

Sleep-away Camp:
13-16 Feb plus Fri night dinner 18th Feb @ PAI House
Location: Braeside Activity Centre

Cost £320
The cost of camp includes transport to and from camp, leaving from and returning to PAI House, London NW11.
All Chanichot will need to meet and be collected from PAI House.

Applications received after 9 Feb will incur a £20 late admin fee.

Please fill in this form and send payment by online transfer to reserve a place. Applications will not be processed unless payment is received. Please email admin@ezrayouth.com if you complete this form and then decide to cancel your application.

Acceptance emails will be sent out by the beginning of February to confirm if you have a place or are on the waiting list.

Refunds for cancellation will be at the discretion of the organisers and subject to a cancellation fee.

Ezra UK reserves the right to refuse any application at their discretion. Places will be allocated according to the discretion of the directors.
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First Name *
Surname *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Name of School *
School Year *
Home Address *
Post Code *
Home Phone Number *
Chanicha Mobile Phone Number (optional)
Chanicha Email Address (optional)
Parent name *
Parent email address *
Please check spelling is correct. All camp information before and during camp will be sent to this email address so please ensure you check it regularly and that emails from admin@ezrayouth.com are not going into your spam folder.
Parent email address - optional second address
Please check spelling is correct.
Parent contact number *
If you will not have access to this number during camp please let us know.
Alternative emergency contact number *
Name of reference (Teacher or Family Rabbi) *
Contact number of reference (Teacher or Family Rabbi) *
My child has asthma *
Required
My child has the following allergies: *
If your child has any allergies / asthma please provide further details below
When was the last time your child had a tetanus injection? *
Any prescribed medicines / painkillers must be handed in at departure in a clearly labelled ziploc bag. Please outline which medications your child takes, how often they should be given, and dosage.
If your child requires non-prescribed medication whilst on camp, would you be happy for Ezra to provide them with paracetamol, plasters, savlon, Antihistamine, Immodium or Ibruprofen? *
Does your child have any of the following conditions or a history of:- Special Educational Need (e.g. Autism, Aspergers, ADHD, dyslexia); Mental Health condition (e.g. Eating Disorder, Self-Harm, Depression, Anxiety, Panic Attacks, Bipolar);  Medical condition (e.g. Diabetes, Heart condition, IBS, Epilepsy, Asthma); Physical condition (e.g. Hypermobility, broken limbs);  Behavioural issues *
If your child has received counselling/therapeutic support for something within the past 2 years please provide: Name and address of counsellor, The amount of time your child was in counselling, Date of last consultation (please write ongoing if it hasn’t finished)
Please tell us if there is anything that would be helpful to know e.g. homesickness, enuresis, confidence issues, recent bereavement, family member with a serious illness or any other medical condition.
GP Name and Number *
I would like to book for Ezra Winter Camp for INTER GIRLS. *
Please pay £320 by online transfer, the details are: Account Name: Ezra Youth Movement, Account Number:00006407, Sort Code:30 93 50. Please use reference code first name, surname, WCIG e.g. NameNameWCIG  
Required
I give my permission, and my daughter aged over 12 gives permission, for Ezra Youth Movement to take pictures of my child / herself during this trip to use for promotional purposes. *
Ezra has a strict gadget policy at camp. By attending camp you and your daughter agree that she will not bring a smartphone, or any device with internet connectivity or a screen bigger than that of an I-pod touch to camp. *
Required
I agree with the following statement:  I am the parent/guardian of the above mentioned participant. Should the occasion arise, I give my consent to any emergency treatment necessary. I therefore authorize the group leader(s) to sign on my behalf, any written form or consent for medical treatment,provided that in the opinion of the Doctor or Surgeon concerned, any delay in obtaining my signature could endanger health or safety. *
Required
My daughter will take a lateral flow test for covid before attending camp and will only attend if the test is negative. She will not attend if she needs to isolate for any covid related reason. Should she contract covid at camp, we will not hold Ezra responsible for this or any consequential health issues. * *
Required
Should my daughter contract covid during camp I will collect her at the earliest possibility at my expense and understand that I will not be refunded for her place. *
Required
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