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Camp Extreme Girls Participant Application 2018
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Max file size: 20MB
APPLICANT PREFFERED FIRST NAME
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APPLICANT FIRST NAME AS IT APPEARS ON ID
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Hebrew Name
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Last Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Applicant Email
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Age
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Current Grade
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Home Phone
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Date of Birth
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Citizenship
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Applicant Cell Phone
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Place of Birth
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Social Security Number
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PLEASE LIST ANY KNOWN ALLERGIES
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ADOPTED?
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Yes
No
IF ADOPTED, WHEN?
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Valid Passport
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Yes
No
Option 3
Issuing Country
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Expiry Date
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Passport Number
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Emergency Contact (other than parents)
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Relationship to Applicant
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Emergency Contact Phone
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How did you learn about this program?
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Family Information
FATHER'S FIRST NAME
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FATHER'S HEBREW NAME
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FATHER'S LAST NAME
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DATE OF BIRTH
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(1)LIVING?
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Yes
No
(1)IF NO, CAUSE OF DEATH:
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(1)ADDRESS (IF DIFFERENT FROM THE APPLICANT'S)
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(1)OCCUPATION:
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(1)HOME PHONE:
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CELL PHONE
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BUSINESS PHONE
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(1)FAX
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(1)ALTERNATIVE PHONE:
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FATHER'S EMAIL
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MOTHER'S FIRST NAME
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MOTHER'S HEBREW NAME
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MOTHER'S LAST NAME
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DATE OF BIRTH
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(2)LIVING
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Yes
No
(2)IF NO, CAUSE OF DEATH:
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(2)ADDRESS (IF DIFFERENT FROM THE APPLICANT'S):
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(2)OCCUPATION:
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(2)HOME PHONE
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CELL PHONE:
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BUSINESS PHONE:
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(2)FAX
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(2)ALTERNATIVE PHONE:
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MOTHER'S EMAIL
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PARENT’S MARITAL STATUS:
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Married
Divorced
IF DIVORCED, WHO HAS LEGAL CUSTODY?
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SISTERS:
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0
1
2
3
4
5
BROTHERS:
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0
1
2
3
4
5
PLEASE LIST SIBLINGS IN CHRONOLOGICAL ORDER; INCLUDING NAME, AGE, AND GENDER
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Past Summer Program History
Dates(#1)
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Name Of Camp(#1)
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Length of Camp(#1)
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Counselor Name(#1)
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Reason for Not Returning(#1)
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Date(#2)
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Name Of Camp(#2)
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Length of Camp(#2)
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Counselor Name(#2)
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Reason for Not Returning(#2)
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Date(#3)
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Name Of Camp(#3)
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Length of Camp(#3)
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Counselor Name(#3)
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Reason for Not Returning(#3)
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Academic History
Please outline your academic history, including elementary school, beginning with most recent:
Year(#1)
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School Name and Contact Information(#1)
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Last Grade Completed(#1)
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Reason For Leaving(#1)
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Year(#2)
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School Name and Contact Information(#2)
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Last Grade Completed(#2)
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Reason For Leaving(#2)
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Year(#3)
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School Name and Contact Information(#3)
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Last Grade Completed(#3)
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Reason For Leaving(#3)
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Medical or Psychological Treatment
Have you received, or are you presently receiving treatment for any medical or psychological condition?
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Yes
No
If yes, please describe: (Attach additional sheets as necessary)
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Are you currently taking any prescription medication?
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Yes
No
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATION?
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Yes
No
PLEASE DETAIL CURRENT OR PAST PRESCRIBED MEDICATIONS:
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DO YOU CURRENTLY SEE A MENTAL HEALTH PROFESSIONAL?
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Yes
No
HAS APPLICANT EVER BEEN HOSPITALIZED FOR PSYCHIATRIC/PSYCHOLOGICAL REASONS AND/OR BEEN DIAGNOSED WITH A MENTAL DISORDER (I.E. DEPRESSION, OCD, ODD, PTSD
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Option 1
Option 2
Option 3
IF YES, PLEASE GIVE THE DIAGNOSIS, AND DESCRIBE THE CIRCUMSTANCES AND DATES. WHAT EVENTS PRECIPITATED THE ADMISSIONS AND WHAT WERE THE OUTCOMES?
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PLEASE LIST THE MENTAL HEALTH PROFESSIONALS YOU HAVE SEEN IN THE LAST 3 YEARS: (INCLUDING NAME, PHONE, EMAIL, PROFESSIONAL TITLE, AND DATES OF SERVICE)
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Please note that if there is no current therapeutic plan in place, a psychological evaluation may be required pending acceptance to the program
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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)
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Relationship(#1)
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Address(#1)
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Phone(#1)
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Email(#1)
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Name(#2)
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Relationship(#2)
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Address(#2)
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Phone(#2)
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Email(#2)
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Name(#3)
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Relationship(#3)
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Address(#3)
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Phone(#3)
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Email(#3)
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HOW DID YOU LEARN ABOUT THIS PROGRAM?
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I hereby certify that all items on this application are answered accurately and completely to the best of my knowledge
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APPLICANT SIGNATURE:
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PARENT'S SIGNATURE:
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DATE:
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About Us
PROGRAMS
Crisis Intervention
APPLICATIONS
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