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2020 Maimonides ECC Nature Summer Program Registration
Registration is open to all incoming ECC children.
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Email
*
Your email
Student #1: First Name
*
Your answer
Student #1: Last Name:
*
Your answer
Student #1 Gender:
*
Choose
Female
Male
Student #1: Birthdate:
*
MM
/
DD
/
YYYY
Student #1: Weeks attending camp:
*
(Select all that apply)
Week 1 (June 29 - July 3)
Week 2 (July 6 - July 10)
Week 3 (July 13 - July 17)
Required
Student #2: First Name
Your answer
Student #2: Last Name:
Your answer
Student #2 Gender:
Choose
Female
Male
Student #2: Birthdate:
MM
/
DD
/
YYYY
Student #2: Weeks attending camp:
(Select all that apply)
Week 1 (June 29 - July 3)
Week 2 (July 6 - July 10)
Week 3 (July 13 - July 17)
Home Address:
*
Your answer
Home Phone Number:
*
Your answer
Parent 1 Name:
*
Your answer
Parent 1 Cell Phone Number:
*
Your answer
Parent 1 Email:
*
Your answer
Parent 2 Name:
Your answer
Parent 2 Cell Phone Number:
Your answer
Parent 2 Email:
Your answer
Emergency Contact Name:
*
(other than parents)
Your answer
Emergency Contact Relationship to Child
*
(other than parents)
Your answer
Emergency Contact Phone Number
*
(other than parents)
Your answer
Are your child's vaccinations up to date?
*
Yes
No
Please submit vaccination records to
nurses@maimonides.org
as soon as possible for valid registration. Thank you!
Allergies: Please indicate name of student, allergen, severity, and symptoms
*
Your answer
Medications & Treatments: Please indicate name of student, name of medication/treatment, dosage, and timing
*
Your answer
Any Previous Injuries: Please indicate student name, type of injury, severity, and date of injury
*
Your answer
Pediatrician Name and Phone Number:
*
Your answer
Terms
TERMS: I have read the camp application form and agree to the terms and rates stated on the website. I give my child permission to attend all outings. I understand that in any medical situation every effort will be made to reach a parent/guardian. If for any reason I cannot be reached, I hereby authorize ECC Nature Summer Program at Maimonides School to transport my child to the nearest hospital for the necessary medical treatment. ECC Nature Summer Program at Maimonides School is hereby granted the right to reproduce electronic or printed images of its students as part of any summer program-related activity. If there are questions relating to this matter, they may be submitted via email to
rmeyerowitz@maimonides.org
. I hereby certify that my child is healthy and I will notify the ECC in writing of any allergies or conditions that he or she may have. I understand that I must submit a physician's physical examination form including my child’s immunization history. The form must be dated within 12 months of June 1, 2020. Must enter initials for acceptance of terms & conditions:
*
Your answer
Information about billing will be provided soon.
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Must check for registration acceptance.
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A copy of your responses will be emailed to the address you provided.
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