Camp Be’chol Lashon Additional Forms

Please fill out the forms below before the start of camp.

Medical Info
Camper Info

Medical Info

Camper & Parent/Guardian Info

Camper's name *

First

Last

Parent/Guardian's name *

First

Last

Parent/Guardian's name

First

Last

Phone number *

Additional phone number

Email *

Camper's address *

Address Line 1

Address Line 2

City

State

Zip Code

Camper's additional address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

We will contact this person in the event that the parent/guardian listed above is not available.

Primary emergency contact's name *

First

Last

Relationship to camper *

Phone *

Address *

Address Line 1

City

State

Zip Code

Additional emergency contact's name

First

Last

Relationship to camper

Phone

Address

Address Line 1

City

State

Zip Code

Medical Info

Insurance company *

Policy number *

Group number *

Policy holder's name *

First

Last

Physician's name *

Physician's phone *

Dentist's name *

Dentist's phone *

Date of camper's last tetanus shot

Medications

Name of medication(s)/supplement(s), dosage, and directions for use: *

Please note: All medications your child takes, including over the counter, as needed, and prescription need to be brought in a sealed container or plastic bag with their name and directions for use. There must be enough medication (prescription and over the counter) to last the duration of camp. Unused medication will be returned at the end of camp. All medications are kept with medical staff on camp grounds. No camper is allowed to keep medication in their bunk.

Please list all allergies your child has including drug, food, insect stings, hay fever, asthma, animal dander, etc., and accompanying symptoms. *

Does your child have difficulty sleeping or urinate in bed? If so, please explain how you handle this at home. *

My child has been vaccinated against Covid-19.

Yes (Please send a picture of your child's vaccination form to camp@globaljews.org)
No
My child is too young to be vaccinated

Is your child able to swim without flotation devices? *

For girls: Has your child menstruated?

Is there any additional information that would aid our camp staff in taking care of your child? Do they have any behavior, physical, emotional, or mental health challenges we should be aware of?

Authorizations

Please agree to the following statements and sign below. *

This health history is correct to the best of my knowledge, and the camper named above has permission to engage in all camp activities as noted.
I certify that I am the camper's legal parent or guardian, and give permission for said camper to use camp transportation to participate in offsite activities.
I give consent for Camp Be'chol Lashon medical staff to dispense my child's prescription medications to him/her, as well as over-the-counter medications, sunscreen, and insect repellent.
I acknowledge and understand there are inherent risks associated with many camp activities. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my attendance at Camp Be'chol Lashon is a privilege and as a consideration for this privilege, I release Camp Be'chol Lashon, including its employees, agents, and trustees, from responsibility for my accidental physical injury, including death or illness, and loss of personal property while at camp or during Camp Be'chol Lashon sponsored travel to and from camp. This release is also intended to include all claims made by the family, estate, heirs, personal representative or assigns. I grant permission for my child to participate in all special trips off the camp property with the proper staff supervision.
I authorize Camp Be'chol Lashon staff to seek any medical care necessary for my child, including basic first aid on camp grounds or care at the nearest hospital, in case of an emergency. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes as outlined under HIPAA regulations; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Camp Be'chol Lashon to secure and administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named herein. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, and is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgement as to the requirements of such diagnosis or medical, dental, or surgical treatment.
I hereby grant to Camp Be'chol Lashon the right to use, reproduce, and/or distribute photographs, films, videotapes, and sound recordings of my child, without compensation or approval rights, for use in material created for the purposes of promoting the activities of Camp Be'chol Lashon.

Signature *

Phone

Camper Info

Name *

First

Last

Email address and/or social media handles (so we can stay connected with you after CBL) *

What are you most looking forward to at camp? *

What concerns do you have about things at camp that you might not like? *

What are your favorite family traditions? *

Do you have favorite Jewish traditions? If so, what are they? *

Do you know anyone who will be at camp this summer? If so, who? *

Describe yourself with 5 different words: *

Code of Conduct

I pledge to do the following while at camp: *

I will physically and emotionally respect myself, my peers, staff, and the camp grounds.
I will ask a staff member for support if I am feeling challenged.
I will be open to learning more about myself and others.

I pledge to NOT do the following while at camp: *

I will NOT harm myself, my peers, staff, or the camp grounds.
I will NOT judge that which is new to me.
I will NOT leave my group or activity without permission.

I accept that if I fail to keep these pledges, I risk losing valuable camp privileges, including being at Camp Be'chol Lashon. Please sign electronically below in the presence of your parent(s) or guardian(s).

Message

Camp Be’chol Lashon Additional Forms

Medical Info

Camper & Parent/Guardian Info

Emergency Contact

Medical Info

Medications

Authorizations

Camper Info

Code of Conduct

Summer 2023

Walker Creek Ranch

Dates

Rates

Support Our Work

Camp Be’chol Lashon Additional Forms

Medical Info

Camper & Parent/Guardian Info

Emergency Contact

Medical Info

Medications

Authorizations

Camper Info

Code of Conduct

Summer 2023

Walker Creek Ranch

Dates

Rates

Support Our Work

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