TZAFON REGION UNITED SYNAGOGUE YOUTH

c/o Sandra Goldmeer 30 Farmingdale Road Latham, NY 12110

518-859-1241 – goldmeeruscj@gmail.com www.tzafon.org

President ELYSSA STEINBERG president@tzafon.org Religion/Education V.P. ELENA POLLACK reled@tzafon.org Social Action/Tikun Olam V.P. RACHEL SUITOR sato@tzafon.org Israel Affairs V.P. EZRA GOLDMEER israel@tzafon.org Membership/Kadima V.P. SOPHIE WEINER memkad@tzafon.org Communications V.P. EMILY WEINFURTNER communications@tzafon.org

Director of Youth Activities SANDRA L. GOLDMEER regionaldirector@tzafon.org

Youth Commission Chairperson ELLEN WEISS LIPPA

United Synagogue of Conservative Judaism 820 Second Avenue 10th Floor New York, NY 10017-4504 USY International President MICHAEL SACKS President RAYMOND GOLDSTEIN Executive Vice President RABBI STEVEN WERNICK USY Director RABBI DAVID LEVY

MAY 20, 2013

DEAR PARENTS — You are receiving this note because your child/ren was either a participant in a USY or KADIMA regional program this past year, and/or is of age to get involved in the United Synagogue Youth Program. To that end, we wanted to let you know/remind you of a fabulous opportunity to get involved Judaically in a much more exciting and informal setting.. Whether they will be of Kadima age (grades 6-8) next year, or whether they are eligible for USY (grades 9-12), we would like to invite your child to join us for ENCAMPMENT, which is the kickoff of our programmatic year here in Tzafon!

WHAT IS ENCAMPMENT ???, you might ask?? It is 6 days of awesome programs and fun and is one of the best ways to end off the summer (August 15-20, 2013). Kadima and USY-aged children are eligible to attend (Entering Grades 6-12). Some of your children have already attended this amazing week and we look forward to having them back with us this year. Encampment takes place at Camp Ramah in the Poconos along with kids from not only Upstate NY, but Pennsylvania and South Jersey. And best of all, the price is right... 6 days of "getaway" for only $475. I know that that sounds like a lot of money, ... but considering it includes transportation, lodging, food, programs and a camp shirt, it is really a great deal! And most importantly it is THE TIME OF YOUR

LIFE!! To make it even better, we have discounts available... if you send in a either the complete application and payment or the application and a $100 deposit postmarked before June 25th, the cost is $460, and are sending more than one child, the second and consecutive sibling(s) can save another $15 (the first sibling goes at the base price).

Enclosed are: 1) our Full Encampment '13 Application 2) an additional poster about Camp. Please note: Scholarships may be available from your Synagogue, and we have some limited funding as well. Please contact me ASAP if this would allow your child to attend. Money should NEVER be the reason your child does not join us! If you have questions, please contact me!! I'd love to talk to you about it!! HOPE TO SEE YOUR Child/ren AT ENCAMPMENT!!

Sincerely,

Sandra Goldmeer Sandra Goldmeer Regional Youth Director, TZAFON

HONORARY PRESIDENTS: Dan Rubin, David Jevotovsky, Ethan Glass, Lauren Kaufman, Chelsea Wagner, Aviva Bates-Gambitsky, Rachel Naparstek, Judith Simons, Tovah Fishman-Larsh, Omri Levin, Andrew Friedson, Sarah Kay, Rachel Brenner, Jaclyn Sisskind, Rebecca Saat, Rachel Arcus, Joseph Zeidner, Jennifer Richardson, Hannah Feinberg, Jason Judd, Jessica Kaplan, Tamar Silton, Akiva Silton, Joshua Kanter, Jeffrey Scheer, Gary Susswein, Michael Sherman, Bobbi Berenbaum, Chaim Singer, Meir Sherer, Barry Safeer, Andrea Lipton, Robert Freeman, Daniel Lehmann, Ethan Kanter, Lesley Pearl, Joyce Stein, Brian Harding, Robbin Feibus, Richard Lehmann, Howard Goldenburg, Hillary David Ring, Howard Stern, Wallace Schwartz, David Schwartz, David Feierstein, Sanford Schwartz, Paul Ruffer, Carol Wolkin, David Getelson, Marcia Greenman Lebeau, Arnold Hammer.

TZAFON ENCAMPMENT ‘13 Registration Form Please return this ENCAMPMENT ’13 packet, all listed paperwork, and full payment to the address listed below. Consult the checklist at the bottom of this form to ensure that you turn in a complete application packet. Registration cannot be

guaranteed without it.

BASIC INFORMATION: Name: ______________________________________________

Address: ______________________________________________________________________________

Home Phone: ______________ USYer Cell Phone: _______________ Parent Cell Phone:_____________ Email Address: ________________________ Parent Email Address: ______________________________ Chapter: _____________________________

Please use this checklist to help ensure that you submit a complete application packet to the address listed below by AUGUST 1, 2013:

Note: Earlybird Rate only applies to applications RECEIVED by 6/25/2013

____ TZAFON REGION –APPLICATION form

NOTE: Completed application and payment must be received by AUGUST 1st .

Applications received after AUGUST 1st , will be accepted on a space available basis only.

Applications received after AUGUST 1st might not be able to be accommodated.

____ PAYMENT (Please see FEE PAGE)

___ CODE of CONDUCT form

____ CONSENT, AUTHORIZATION and RELEASE form for 2013 -2014

____ Health History and Parent Questionnaire

____ PHYSICAL EXAM FORM

____ Copies of present Medical Insurance Card (Front and Back)

____ TZAFON USY/KADIMA Medication Card (If applicable)

NOTE: CANCELLATION POLICY: There will be a $100 cancellation fee charged between July 15th and

August 1st . All cancellations must be submitted in writing BEFORE August 1st . NOTE: There will be no

refunds after this date – for ANY REASON.

Please make checks payable to USCJ/Tzafon USY and send them to:

TZAFON USY Encampment/Kamp Kadima,30 farmingdale Road, LATHAM, NY 12110

For more information, please call the Sandra Goldmeer, Regional Youth Director,

at 518-859-1241, or email: regionaldirector@tzafon.org

ENCAMPMENT 2013 FEE PAGE Please include this page when you return your application

Your Encampment registration fee includes round trip coach bus transportation to and from Camp

Ramah in the Poconos from designated pick-up points throughout the Region ***, kosher meals for the duration of the program, use of all camp facilities, and all programming expenses.

*** Due to the route we take to Encampment, we have fewer total Regional pickup points than for regular conventions… It may require you to drive to a neighboring city to get your child to the closest pickup point.

Bus stop determination is based on cost and from where our USYers are coming. FINAL SCHEDULES will be distributed 2 weeks prior to Encampment!!

� Enclosed is my registration for $475.00. NOTE: Completed application and payment must be received by AUGUST 1st .

Applications received after AUGUST 1st , will be accepted on a space available basis only.

Applications received after AUGUST 1st might not be able to be accommodated.

� EARLY BIRD DISCOUNT -- Applications must be RECEIVED by JUNE 28th to qualify

for a $15 Earlybird discount.

**� Sibling Discount Price – Register your first child at the regular registration price

and each additional child at $15.00 off the registration price.

Total Amount Enclosed $________________ (including Registration Fee and any discounts which may apply)

Please note:

1. The application and health form, with all signatures, must be completed. Health forms are due no later

than August 1st .

2. CANCELLATION POLICY: There will be a $100 cancellation fee charged between July 15th and August 1st .

All cancellations must be submitted in writing before August 1st . NOTE: There will be no refunds

after this date – for ANY REASON.

3. SYNAGOGUES and the REGION have scholarships/funding assistance. MONEY should NOT be the reason

your child does not attend. Please contact your Shul AND Sandra Goldmeer to talk about options!

Please make checks payable to USCJ/Tzafon USY and send them to:

TZAFON USY Encampment/Kamp Kadima,30 farmingdale Road, LATHAM, NY 12110

For more information, please call the Sandra Goldmeer, Regional Youth Director,

at 518-859-1241, or email: goldmeeruscj@gmail.com

CHECK ONLY ONE: ���� USY (9-12th grade of 9/13) ���� Kadima (6-8th grade as of 9/13)

Name________________________________ Chapter_______________________Grade as of 9/13_______� Male � Female

USYers Phone _________________________________ Parents’ Phone___________________________________

Home Address______________________________________________________________________________________

City________________________ State______ Zip Code_________________ Date of Birth:____/_____/____ Age:_____

USYer E-mail ________________________________________ Parents’ Email______________________________________

Region: � Tzafon Years previously attended Encampment:_____________

T-shirt size: (adult sizes only): � Small � Medium � Large � X-Large � XX-Large

Vegetarian:Vegetarian:Vegetarian:Vegetarian: � Yes �No If yes, please describe to what extent____________________________________________

Lactose Intolerent:Lactose Intolerent:Lactose Intolerent:Lactose Intolerent: � Yes � No GLUTEN FREEGLUTEN FREEGLUTEN FREEGLUTEN FREE???? � Yes � No FOOD ALLERGIES??FOOD ALLERGIES??FOOD ALLERGIES??FOOD ALLERGIES??:____________________________

I have a sibling attending Encampment � Yes (see see see see Fee SectionFee SectionFee SectionFee Section for more information for more information for more information for more information about Sibling Discountsabout Sibling Discountsabout Sibling Discountsabout Sibling Discounts)

Emergency Information: Please list an emergency contact person, in the event a parent cannot be reached.

Name_________________________________________________________ Relationship________________________

Address_______________________________________ City________________________ State_______ Zip__________

Home Phone (______)_______________ Work Phone (______)______________ Cell Phone (______)_____________

Health Insurance Carrier_______________________________________________________________________________

ID #________________________________ Phone Number of Insurance Carrier (________)________________

Address of Company_________________________________________________________________________________

*Please attach a copy of your insurance card including both the front and back sides. I hereby give permission for my child

to participate in the Quad-Regional Encampment and Kamp Kadima, August 15-20, 2013 and release Camp Ramah and

the EPA, Hagesher, Tzafon Regions of the United Synagogue of Conservative Judaism from any liability in case of accident

incurred en route to or from and throughout Encampment. I understand that in case of illness or accident my child is

covered by my medical insurance. My child is responsible to USY or Kadima for any damages caused to camp property. I

further understand that any USYer or Kadimanik involved with alcohol and/or drugs during the Encampment period will

be sent home immediately at the parent(s)’ expense. In case of medical and/or surgical emergency, I hereby give

permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for and to order

injections, anesthesia or surgery for my child as named above if I cannot be reached and such care is deemed necessary.

I certify that all information in this application is up to date and accurate. I accept all the terms and provisions that

appear throughout the application.

Parent Name_____________________________ Signature X __________________________________ Date__________

Parent’s Phone # for the period of 8/15-8/20 (_________)_____________________________________________

Parent’s work #:______________________ Cell Phone #:_____________________ Home#:_____________________

2013 ENCAMPMENT • EPA, HAGESHER, TZAFON

AUGUST 15-20, 2013 • CAMP RAMAH IN THE POCONOS

TZAFON REGIONAL REGISTRATION FORM

Please place a current passport size

photo here. A current photo is

required to process this application.

Name of PartName of PartName of PartName of Participant_______________________________________________ Region_____________________________icipant_______________________________________________ Region_____________________________icipant_______________________________________________ Region_____________________________icipant_______________________________________________ Region_____________________________

INTERNATIONAL AND REGIONAL CODE OF CONDUCT FOR USYERS, KADIMANIKS AND STAFF

Year after year, the Kadima and USY members have a great time at our Regional activities. Because of our genuine concern and care for each member, and so that all can enjoy these programs to the fullest extent without interference, we have a Code of Conduct at Regional events. These rules are basic, simple and fair, and in the best interest of all participants.

It is the responsibility of parents to review these rules and stress their importance to their children as we will expect full compliance. We reserve the right to call parents of individuals whose behavior is inconsistent with the Code of Conduct below to personally pick up their child from the event (with no refund) and/or to exclude their child from future events.

1. There is to be no smoking.

2. There is to be no possession or use of any narcotics, marijuana, other illegal drugs or prescription drugs not prescribed for the user. Matches, firecrackers (or similar devices), knives, sharp or dangerous objects, as well as the items mentioned before are not permitted to be brought to camp, nor may they be in the possession or cabin of any Camper.

3. There will be no possession or consumption of ANY alcoholic beverages.

4. There will be no shoplifting or other theft of any kind. No gambling is permitted.

5. If a USYer/Kadimanik is caught in possession of/or using alcohol or illegal drugs, he/she will immediately be sent home at his/her parents’ expense. Furthermore, USY International policy states: “Anyone violating any such rules at a regional event for the infraction of these rules is barred from International events for one year following the infraction. Individuals will also be prohibited from participating in the next major regional USY program and other events occurring in the interim, and prohibited from chairing events or staffing programs for six months. Individuals already in leadership positions will be removed. A major Regional event is a regionally sponsored overnight event, such as a convention, Kinnus or Encampment. These events will also include (but are not limited to) the International USY Convention and USY summer programs.” The Region reserves the right to impose additional sanctions in connection with this or any other improper behavior as it sees fit.

6. All participants are expected to be in sessions (services, meals, study groups, etc.). Swimming is permitted only at scheduled times when certified supervision is present. The pool and lake areas are off limits at all other times. Because the campgrounds are very spacious, certain other areas will be announced as off limits for your safety. NO USYer/Kadimanik may leave the premises without prior approval of the Regional Director and a parent.

7. All males are expected to bring a tallit and tefillin. All males are required to wear a kipah during all services, meals and study groups. Tallit/tefillin must be worn for morning services where appropriate. Females are encouraged to do the same, if that is their personal practice.

8. Each participant is expected to maintain proper decorum and attitude during the entire program. Disruptive behavior (including, among other things, inappropriate sexual behavior) will not be tolerated. Your parents will be responsible to pay for any damage you may cause.

9. Proper dress is expected of everyone. For Shabbat, males must wear a shirt and tie or sweater, no jeans or sneakers.

Females are to wear dresses or skirts of knee length. Dressy pants are allowed. All USYers/Kadimaniks shall wear clothing appropriate to the event/location. Please note that you may not wear tank tops, halters, see through blouses or strapless shirts to regional events.

10. All housing/rooming/bunking assignments are final. Changes in bunking can only be made by the Regional Director or her designee. All USYers must be in their assigned bunks at curfew and remain there. Males are not permitted in sleeping rooms of females and females are not allowed in the sleeping rooms of males.

11. Each participant is expected to conduct him/herself appropriately as a Conservative Jew (including through the observance of Shabbat and Kashrut), in accordance with applicable standards of the Law and Standards Committee of the Rabbinical Assembly and/or the local Rabbinical Authority.

12. No USYer shall violate any civil or criminal law, including but not limited to, those related to tampering of or destruction of property, and destruction of one’s own or another person’s physical and/or mental integrity. Inappropriate or unwelcome physical contact or language, indecent attire or public nudity, shall not be permitted. Any damage caused to property of other USYers or Camp property by a USYer will be at the USYer family’s expense.

13. The Region reserves the right to search the room and belongings of any attendee if it has reasonable grounds to believe that such a search is necessary to secure and maintain the health, safety and/or welfare of the program and/or its participants. The USY or Kadima Director, in consultation with the Regional Youth Commission, reserves the right to enforce other rules relating to the integrity of the Regional Youth Program and/or the health, safety or welfare of its participants.

***I have read these rules and understand them fully. I certify that I will adhere to this Code and will conduct myself in a manner reflecting credit upon myself,

my Chapter, congregation and community. Any violation of this code of conduct may result in the participant being sent home at his/her parents' expense. The Regional Director has the sole discretion to send a participant home. X ____________

SIGNATURE OF USYer/Kadimanik

I , the parent/guardian of , a minor, who will be participating in USY/Kadima Regional programs, do hereby certify that I have read the Code of Conduct set forth above. I do hereby agree that if my child who has signed the above Rules of Conduct fails to adhere to the Code, then in such event those persons in charge of the program may send my child home at my expense. I understand that the Regional Youth Director has the sole discretion to send my child home.

I have been made aware of the fact that the events in which my child is participating may be photographed by either amateur or professional photographers, that the photographs taken may be used both for purposes of reporting on the event or for such other use as the USY or Kadima organization may determine. I have no objection to the pictures taken being used at any time for promotional use. It is my understanding that by signing this document I consent to the use of the pictures just referred to for any purpose whatsoever.

X _______________

SIGNATURE OF PARENT DATE

NOTE: THIS FORM IS KEPT ON FILE FOR ALL REGIONAL PROGRAMS OF THIS PROGRAM YEAR UNITED SYNAGOGUE OF CONSERVATIVE JUDAISM

DEPARTMENT OF YOUTH ACTIVITIES --TZAFON REGION 30 FARMINGDALE ROAD LATHAM, NY 12110 518.859.1241 Goldmeeruscj@gmail.com

CONSENT, CONSENT, CONSENT, CONSENT, AUTHORIAUTHORIAUTHORIAUTHORIZATIONZATIONZATIONZATION andandandand RELEASERELEASERELEASERELEASE 2012012012013333----2012012012014444

NAME: ________________________________________, (“MINOR”) DATE OF BIRTH: ___________________

THIS CONSENT, AUTHORIZATION AND RELEASE (“Consent”) is given to The United Synagogue of Conservative Judaism, its Northeast District, and Department of Youth Activities (collectively “USCJ/USY”) headquartered in Albany, NY, in connection with my child’s participation in any Regional USY/Kadima Activity (“Scheduled Activity”) for the 2012-2013 Program year. PLEASE READ AND INITIAL EACH PARAGRAPH AFTER THE PARAGRAPH NUMBER TO SHOW YOUR CONSENT

AND THEN SIGN AND DATE THE BOTTOM OF THIS PAGE. INITIAL

1. ___ The Minor has my consent to attend and to participate in a Tzafon Regional Activity. There are no limitations or restrictions of any kind whatsoever on such participation unless checked here ___ and an explanation is attached.

2. ___ The Minor has been instructed by me, and understands and agrees, to comply with all rules, regulations and Code of Conduct established by USY/KADIMA and the official instructions and directives of all authorized staff members, volunteers, agents and employees of USY/KADIMA (“Personnel”). All references to “you” or “your” mean USY/KADIMA and its Personnel.

3. ___ You, acting as my authorized agent and at my sole cost and expense, are expressly authorized to engage appropriate health care providers to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions. There are no exceptions or limitations to the foregoing, unless checked here____ and specific written instructions are attached.

4. ___ Unless checked here ____ and I have attached specific written instructions, directions or other specific data to the contrary, you may assume that the Minor has no medical disabilities, allergies or other limitations of any kind whatsoever that may limit participation in the Scheduled Activity.

5. ___ I expressly release and agree to indemnify and hold USCJ/USY, its agents, Board of Directors, employees, representatives, and legal counsel, free and harmless from any and all liability, charges, claims, costs and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with the acceptance and participation of the Minor in the Scheduled Activity. The foregoing Release is unconditional and without reservation of any kind, except only for such acts or omissions that arise out of your intentional or negligent wrongdoing where there is no fault by the Minor or by my failing to disclose pertinent information to you.

6. ___ I represent to you that I have sole, full and legal power and right to execute this Consent, and acknowledge that you will be relying on my representations and statements, and on the information supplied to me.

7. ___ If this Consent is signed by more than one person, all references to the singular shall include the plural, jointly and severally.

8. ___ I give USCJ/USY permission to use any photographic, video or audio representations of my minor that may be taken during the Scheduled Activity, be it in print, in Internet materials, or in other media produced by USCJ/USY for publicity, promotional, or any other purposes without further permission.

I HAVE READ AND FULLY UNDERSTAND THE IMPORTANCE AND EFFECT OF THE FOREGOING CONSENT, AUTHORIZATION AND RELEASE; I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND A LICENSED

PHYSICIAN AS I DEEMED NECESSARY BEFORE SIGNING THIS DOCUMENT; I HAVE RETAINED A COPY OF THIS

DOCUMENT FOR MY RECORDS; AND I HAVE VOLUNTARILY SIGNED THIS CONSENT ON ___________________, 20______.

Signature _______________________________Relationship to Minor ___________________ Revised 9/1

NOTE: ALL USYER’S/KADIMANIKS MUST HAVE MEDICAL INSURANCE IN ORDER TO PARTICIPATE IN REGIONAL PROGRAMS.

We provide secondary insurance for accidents and illnesses that occur during the Encampment. This means, our insurance carrier will directly settle all charges with your health providers after your primary insurance maximum allowance has been reached in accordance with the schedule in your policy and subject to certain provisions, limitations and exclusions in our policy.

Name:_________________________________ Region:___________________ Grade:__________

E-mail Address:____________________________________________________________________

Are you a USY Chapter Board Member? � yes � no If yes, which position?_________________________

RELIGIOUS INFORMATION RELIGIOUS INFORMATION RELIGIOUS INFORMATION RELIGIOUS INFORMATION –––– USY & KADIMAUSY & KADIMAUSY & KADIMAUSY & KADIMA

Name___________________________ Phone #_________________________ E-mail Address____________________

Your Hebrew Name_________________ Ben/Bat(Father’s Name)_____________ V’ (Mother’s Name)____________

I am a: � Kohen �Levi �Yisrael

I I I I am able toam able toam able toam able to lead the following:lead the following:lead the following:lead the following:

�Kabbalat Shabbat �Weekday Shacharit �Shabbat Shacharit �Weekday Ma’ariv �Shabbat Musaf

�Shabbat Ma’ariv � Weekday Mincha �Kiddush �Shabbat Mincha � Birkat HaMotzi

�Shabbat Torah Service �Read Torah 3-5 Verses �Read Torah 6-10 Verses �Read Haftorah �Aliyah

�Birkat HaMazon (full version) �Hagbah (lifting the Torah) �Glilah (wrapping the Torah) � Gabbai

BUNK REQUESTS:BUNK REQUESTS:BUNK REQUESTS:BUNK REQUESTS:

Name:________________________________ Grade:________ Region:_______________________

� Male � Female

• Bunking is done by grade and gender. Please make certain to list only friends who are in the same

grade as you in Public/Private Day School, and who are the same gender.

• Please be sure that ALL friends you select below also select you on their form.

• Every effort will be made to accommodate your requests.

Request 1:__________________________________ Region:_______________________

Request 2:_________________________________ Region:_______________________

HEALTH HISTORY and PARENT QUESTIONNAIREHEALTH HISTORY and PARENT QUESTIONNAIREHEALTH HISTORY and PARENT QUESTIONNAIREHEALTH HISTORY and PARENT QUESTIONNAIRE

THIS SIDE TO BE FILLED OUT BY PARENT/GUARDIANTHIS SIDE TO BE FILLED OUT BY PARENT/GUARDIANTHIS SIDE TO BE FILLED OUT BY PARENT/GUARDIANTHIS SIDE TO BE FILLED OUT BY PARENT/GUARDIAN AND RETURNED WITH THE APPLICATION.AND RETURNED WITH THE APPLICATION.AND RETURNED WITH THE APPLICATION.AND RETURNED WITH THE APPLICATION.

Name ________________________________________________ Birth Date _________ Sex ___ Age ____ Grade ____

Parent or Guardian _____________________________________ Home __________________Cell ___________

If not available in an emergency, notify: Name _______________________________ Relationship ____________________

Home phone ( ___ ) ___________ Cell phone/business phone ( )

FAMILY MEDICAL/HOSPITAL INSURANCE CARRIER ___________________________________________________

Group # ______________________________________ Policy # ______________________________________ ____

Please attach a photocopy of the front and back of your medical insurance card and prescription plan card

TO BEST CARE FOR YOUR CHILD, WE NEED YOU TO PROVIDE AS MUCH DETAIL AS POSSIBLE!

HEALTH HISTORY: ALLERGIES: DRUGS:

FOOD: ENVIRONMENTAL:

LIST YOUR CHILD’S MEDICATIONS:

(INCLUDE DAILY MEDICATIONS, AS NEEDED MEDICATIONS, LIST REASON FOR TAKING MEDICATION:

HERBAL SUPPLEMENTS AND VITAMINS)

Is your child recovering from addiction, eating disorders or psychological conditions?

Operations, hospitalizations, serious injuries or illnesses (specify and give date) _________________

Has your child spent a week away from home previously? ____________

Has child ever been denied enrollment or sent home early from a camp or weekend? ______

If yes, please explain ________________________________________________________________________________

Describe any circumstance that would result in (a) situation(s) not compatible with group living or any other possibility of problem

behavior. ________________________________________________________________________________________________

Are there any special family situations that we should be aware of? ___ Death _____ Divorce ____ Recent separation

____ Serious illness ____ Other Please provide details:

Please list all doctors (and their specialty) that are currently participating in your child’s care:

_____________________________________________________________________________

IF THERE ARE ANY CHANGES OR ADJUSTMENTS IN MEDICATION, WE MUST BE NOTIFIED IMMEDIATELY!

Page 5

AUTHORIZATION AND VERIFICATION (This box must be completed)

The above information and health history is correct and complete to the best of my knowledge. I acknowledge that failure to disclose any medical

information, treatment or medication, could result in my child being removed from the program and sent home from camp at my expense. I, the parent

or legal guardian, of the applicant, state that he/she is in good normal health, has no abnormal physical or mental handicaps and has my permission to

engage in all prescribed camp activities except as noted under restrictions or modifications above or on the Physical Examination Form.

I hereby give my permission to the camp:

1. To provide ongoing health care.

2. To select medical personnel and to order X-rays, routine tests or treatments for my child.

3. In case of medical emergency, accident or a serious health problem where immediate treatment is deemed necessary, I give permission to

the physician selected by the Regional Youth Director, Regional Kadima Director or the person designated by the Region to hospitalize,

secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named above. In such case, every effort will be

made to contact the parent or guardian of the applicant.

I am aware that this form may be photocopied for use by medical caregivers.

Parent/ Guardian Signature _________________________________________Print Name _____________________________________ Date ________

PHYSICAL EXAMINATION FORM To be filled out by licensed physician.

NAME OF CHILD: ___________________________________

DATE OF EXAMINATION: ___________________ NOTE: This side is REQUIRED for ALL PARTICIPANTS The date of examination must be have been in the last 8 months (Since January 2013).

Please record the date (month and year) of basic immunization and most recent booster doses:

Vaccines Year of Basic Immunization Year of Last Booster

Diphtheria Pertussis (Whooping Cough) Tetanus

Or

1 2 3

1 2

Tetanus Diphtheria

Or

Tetanus

Oral Polio (Sabin)* TOPV

Injectable Polio (Salk)

Measles (hard measles, red measles, Rubeola)

Mumps

Rubella (German measles, 3-day measles)

Other

Tuberculin test given ______(most recent)

Health Examination by Licensed Physician Code: √ -- Satisfactory x – Not Satisfactory (explain) Hgt. ________ B.P. _______ Urinalysis test done ___________ Wt. ______________ Hgb. Test done _________ Eyes _______ Extremities __________ Glasses _________ Posture (Spine) _________ Ears ____________ Skin ________ Nose _______ Allergies (please specify) _________________________________________________________ Teeth _______ Heart _______ Menstrual history ____________________ Lungs _________ Abdomen _____________ Throat __________ Genitalia __________ Hernia ______________ General appraisal _____________________ I have examined the above camp applicant on (date) ______________________________________________________ In my opinion, the above condition does _____/does not ______ preclude his/her participation in an active camp program. The applicant is under the care of a physician for the following condition(s): ________________________________________________________________________________________________________ Current treatment (include current medication): ________________________________________________________________________________________________________________________________________________________________________________________________________________ Is child recovering from addiction, eating disorders or psychological conditions?_________________________________________ ________________________________________________________________________________________________________ Explanation of any reported loss of consciousness, convulsion, or concussion __________________________________________ ________________________________________________________________________________________________________ Does applicant have epilepsy? Yes ____ No ____ Does applicant have diabetes? Yes ______ No______ Recommendations and Restrictions While at Camp (diet, medicine, treatment, etc.) ___________________________________ ________________________________________________________________________________________________________

Additional Health Information __________________________________________________________________________ X Licensed Physician’s Signature ________________________________________ *By _______________________________ Please print physician’s full name: Full Address _________________________________________________________ Phone (_______)______________________ *Initial if completed by nurse or physician’s assistant.

INSTRUCTIONSINSTRUCTIONSINSTRUCTIONSINSTRUCTIONS

This Health Form may be separated from Camp Application form.

Return To: TZAFON USY/KADIMA Encampment

30 Farmingdale Road, Latham, NY 12110

DEADLINE FOR HEALTH FORM – AUGUST 1, 2013

TZAFON USY/KADIMA Encampment

30 Farmingdale Road, Latham, NY 12110

NOTE: FAILURE TO FOLLOW THESE INSTRUCTIONS MAY MEAN THAT A PARTICULAR MEDICATION MAY NOT BE

DISPENSED OR ADMINISTERED.

If you have any concerns, please contact Sandra Goldmeer, Tzafon USY Regional Director,

at 518-849-1241 or Email her at goldmeeruscj@gmail.com

TZAFON USY/KADIMA MEDICATION CARD

ENCAMPMENT is an exciting, end-of-summer positive Jewish

experience with participants from our

own Tzafon Region (Upstate NY) along

with EPA (Eastern PA) and

Hagesher (Phila PA area and South Jersey)!

It provides Jewish teenagers an informal

opportunity to make new friends and renew

the friendships they might have made at

previous events. At the same time, these

youngsters will live in a completely Jewish

setting where Shabbat and Kashrut are

observed.

Most of our campers are returnees who

create a warm and friendly atmosphere for

all of the new campers. Participants will have

the unique experience to spend time

interacting and making friends from three

USY/Kadima regions!

An ALL INCLUSIVE camp program including accommodations, Transportation from central locations, & a camp t-shirt

Earlybird discount will be available for deposits/applications received thru 6/25/2013 Discounts also available for Siblings

Interested? Email Sandra Goldmeer at Goldmeeruscj@gmail.com

• Talent Show

• Maccabiah

• Israel Programs

• Social Action Programs

• Drama

• Activities

• Kosher Meals

• Snacks

• Chapter Programming Workshops

• Arts & Crafts

• Creative Services

• Intramural Sports

• Pool Activities

• Daily Activities

• Special programming for

• Kadima (6-8th graders) &

• USY (9-12th graders)

• & much more!

HAGESHER ���� EPA ���� TZAFON