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Camp Extreme Girls Participant Application 2018

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APPLICANT PREFFERED FIRST NAME *

APPLICANT FIRST NAME AS IT APPEARS ON ID *

Hebrew Name *

Last Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Applicant Email *

Age *

Current Grade *

Home Phone *

Date of Birth *

Citizenship *

Applicant Cell Phone *

Place of Birth *

Social Security Number *

PLEASE LIST ANY KNOWN ALLERGIES *

ADOPTED? *

IF ADOPTED, WHEN? *

Valid Passport *

Issuing Country *

Expiry Date *

Passport Number *

Emergency Contact (other than parents) *

Relationship to Applicant *

Emergency Contact Phone *

How did you learn about this program? *

Family Information

FATHER'S FIRST NAME *

FATHER'S HEBREW NAME *

FATHER'S LAST NAME *

DATE OF BIRTH *

(1)LIVING? *

(1)IF NO, CAUSE OF DEATH: *

(1)ADDRESS (IF DIFFERENT FROM THE APPLICANT'S) *

(1)OCCUPATION: *

(1)HOME PHONE: *

CELL PHONE *

BUSINESS PHONE *

(1)FAX *

(1)ALTERNATIVE PHONE: *

FATHER'S EMAIL *

MOTHER'S FIRST NAME *

MOTHER'S HEBREW NAME *

MOTHER'S LAST NAME *

DATE OF BIRTH *

(2)LIVING *

(2)IF NO, CAUSE OF DEATH: *

(2)ADDRESS (IF DIFFERENT FROM THE APPLICANT'S): *

(2)OCCUPATION: *

(2)HOME PHONE *

CELL PHONE: *

BUSINESS PHONE: *

(2)FAX *

(2)ALTERNATIVE PHONE: *

MOTHER'S EMAIL *

PARENT’S MARITAL STATUS: *

IF DIVORCED, WHO HAS LEGAL CUSTODY? *

SISTERS: *

BROTHERS: *

PLEASE LIST SIBLINGS IN CHRONOLOGICAL ORDER; INCLUDING NAME, AGE, AND GENDER *

Past Summer Program History

Dates(#1) *

Name Of Camp(#1) *

Length of Camp(#1) *

Counselor Name(#1) *

Reason for Not Returning(#1) *

Date(#2) *

Name Of Camp(#2) *

Length of Camp(#2) *

Counselor Name(#2) *

Reason for Not Returning(#2) *

Date(#3) *

Name Of Camp(#3) *

Length of Camp(#3) *

Counselor Name(#3) *

Reason for Not Returning(#3) *

Academic History

Please outline your academic history, including elementary school, beginning with most recent:

Year(#1) *

School Name and Contact Information(#1) *

Last Grade Completed(#1) *

Reason For Leaving(#1) *

Year(#2) *

School Name and Contact Information(#2) *

Last Grade Completed(#2) *

Reason For Leaving(#2) *

Year(#3) *

School Name and Contact Information(#3) *

Last Grade Completed(#3) *

Reason For Leaving(#3) *

Medical or Psychological Treatment

Have you received, or are you presently receiving treatment for any medical or psychological condition? *

If yes, please describe: (Attach additional sheets as necessary) *

Are you currently taking any prescription medication? *

ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATION? *

PLEASE DETAIL CURRENT OR PAST PRESCRIBED MEDICATIONS: *

DO YOU CURRENTLY SEE A MENTAL HEALTH PROFESSIONAL? *

HAS APPLICANT EVER BEEN HOSPITALIZED FOR PSYCHIATRIC/PSYCHOLOGICAL REASONS AND/OR BEEN DIAGNOSED WITH A MENTAL DISORDER (I.E. DEPRESSION, OCD, ODD, PTSD *

IF YES, PLEASE GIVE THE DIAGNOSIS, AND DESCRIBE THE CIRCUMSTANCES AND DATES. WHAT EVENTS PRECIPITATED THE ADMISSIONS AND WHAT WERE THE OUTCOMES? *

PLEASE LIST THE MENTAL HEALTH PROFESSIONALS YOU HAVE SEEN IN THE LAST 3 YEARS: (INCLUDING NAME, PHONE, EMAIL, PROFESSIONAL TITLE, AND DATES OF SERVICE) *

Please note that if there is no current therapeutic plan in place, a psychological evaluation may be required pending acceptance to the program.

References

Please submit two letters of recommendation with full contact information. At least one letter must be from a school principal or local Rabbi with whom you have a relationship. Please provide the names and addresses of these three persons [not relatives] having knowledge of your character, experience, and ability.

Name(#1) *

Relationship(#1) *

Address(#1) *

Phone(#1) *

Email(#1) *

Name(#2) *

Relationship(#2) *

Address(#2) *

Phone(#2) *

Email(#2) *

Name(#3) *

Relationship(#3) *

Address(#3) *

Phone(#3) *

Email(#3) *

HOW DID YOU LEARN ABOUT THIS PROGRAM? *

I hereby certify that all items on this application are answered accurately and completely to the best of my knowledge.

APPLICANT SIGNATURE: *

PARENT'S SIGNATURE: *

DATE: *

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