Camper Application

Please fill out this application completely.
All credit card transactions take place over our secure server.

Please select one:

Full Summer
First Trip
Second Trip
Second Trip - 14-Day Get Your Feet Wet Program
Second Trip - 3-Day Trial Program
Please select one:

Camper
Chevra Division
CIT
Yaalozu-Mountaineering
CIT-Waiter
Camper's first name: Last name:
Street Address: City:

State/Province: ZIP/Postal code:

Country:
Phone number: Fax number:

Father's Email address:

Mother's Email address:

Camper's email address:
Camper's birthdate: (mm/dd/yy): Current grade:
Camper's yeshiva: Yeshiva's phone number:

Name of camper's rebbi:
Father's name:

Father's occupation:

Father's work number:

Father's cell number:
Mother's name:

Mother's occupation:

Mother's work number:

Mother's cell number:
Parents' marital status: Married   Divorced   Widowed   Separated
Alternate emergency contact: Phone number:

Relationship to camper:
Camps attended:

2017:

2016:

2015:
Where did you hear about Camp Dora Golding?

Will camper need transportation to camp? Yes   No (will drive camper to camp)

If yes, from where? Brooklyn   Queens   Five Towns   Elizabeth   Teaneck
Airport (additional fee applies for Airport)
Other persons living at home:

Name: Age: Occupation/School:

Name: Age: Occupation/School:

Name: Age: Occupation/School:

Name: Age: Occupation/School:

Name: Age: Occupation/School:

References:

Name: Position:

Phone: Address:


Name: Position:

Phone: Address:
Bunkmates requested:

Please note: Although we always try our best to accommodate your requests and keep preferred friends together, it is not always possible, and therefore we cannot guarantee any child's bunkmates.


Name:

Name:

Name:
Special instructions (medical or otherwise):



Credit Card Information


I am hereby applying for the enrollment of my child at Camp Dora Golding for the upcoming season. I am authorizing a credit card charge for the deposit of $700 per trip or $1000 for the entire summer, which includes a non-refundable application processing fee of $300, only once my child has been accepted and registered. The rest of the deposit is refundable until December 1st. I understand that this application is subject to approval and availability.

The balance of my account should automatically be charged to my credit card in two installments:
Half on February 1st and half on April 1st. (There is no extra charge to pay by credit card.)

I agree to pay the balance manually: Half by February 1st and half on April 1st.

Amount to be charged: $700 - One Trip $1000 - Entire summer

Credit card type:
Visa (most preferable)
Discover
American Express
Mastercard (least preferable)

Credit card number: - - - Expiration date: /

Name as it appears on card:

Billing address:
(if different than address listed above)
  1. We will make every effort to protect the personal belongings of every camper. However, the camp is not responsible or liable for equipment or personal property (including money) of camper, while in transit or at camp, whether the equipment or personal property is lost, stolen, or damaged by fire, laundry, or any other cause.
  2. The parent or legal guardian signing this application certifies that the child is both physically and emotionally healthy, and acknowledges that this application will be accepted subject to a complete examination by a physician within three (3) months prior to departure.
  3. DEPOSIT AND PAYMENTS Half of the balance is due by February 1st, and the remainder is due on or before April 1st. If registration takes place after these dates, full payment must be made immediately. Camp fee includes all regular camp activities, laundry, and round-trip transportation. Camp fee does not include medical expenses, tips, or canteen, or luggage transportation. An additional flat fee of $50.00 will be charged to cover the cost of luggage transportation. This fee is the same, regardless of whether it is for one-way or round-trip transportation. Please be certain that all checks made out to the Camp are valid. There will be a $30.00 charge for bounced checks.
  4. REFUND POLICY Any total or partial cancellation prior to December 1st will incur a $300 service fee. After December 1st, NO REFUNDS will be made, and cancellations after this date will result in a forfeiture of any and all funds paid. Due to the seasonal nature of summer camping and the set limitation on spaces offered, it is camp policy not to offer any refund of tuition fees to any camper who leaves or is asked to leave prior to the end of his/her enrollment period. It is also expressly understood and agreed that, if the camper leaves the camp grounds without the express permission of the Camp Director, or if the camper damages or defaces camp property, or if the camper's conduct or influence is not up to the camp's standards, the camper will be dismissed at the sole discretion of the Executive Director with no refund or reduction in fee. Late arrivals, early departures, or absences will not result in a credit or refund. Changing from whole summer to half summer cancels original registration, puts camper at the end of the waiting list, and subjects camper to cancellation fee.
  5. PERMISSION Camp is hereby granted permission to use the camper's name, picture, portrait likeness, and voice for promotional and advertising purposes, whether is be used in the camp's literature, brochure, videotape, website, or other medium, without additional consideration. Permission is also given for the camper to leave camp for the purpose of attending and participating in camp programs such as, but not limited to, Inter-camp games and out-of-camp trips.
  6. FINANCIAL AGREEMENT I agree to be financially responsible for all fees, costs, and expenses incurred during my child's attendance at camp.
  7. MEDICAL AUTHORIZATION AND PARENTAL CONSENT I hereby request that my child attend Camp Dora Golding for this summer season. In the event of an accident, illness, or medical or surgical emergency, I hereby authorize the Camp Director, Doctor, Nurse, or any administrative personnel, if not able to contact me, to act for me according to their best judgment with respect to the care of my child, including any medical and surgical care. I understand that every effort will be made by the camp administration to immediately contact me in the event of an emergency. I hereby release Camp Dora Golding and all persons connected therewith from any and all liability and responsibility in the performance of the above acts and medical services. I understand that I am financially responsible for all costs and expenses which are not covered by my medical insurance. Medical services are provided through the camp infirmary and nurses of the camp. Outside medical services and medicines deemed necessary by the camp medical staff, or by the parents, shall be the responsibility of the parents.

By entering my name below, I hereby indicate that I have read, understood, and agree to all of the above terms. Signature of Parent Date

If you do not hear from us within two weeks, please call to confirm that we received this application.