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Camp Extreme Boys 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 *

Please list any known allergies *

Home Phone *

Date of Birth *

Citizenship *

Adopted? *

Applicant Cell Phone *

Place of Birth *

Social Security Number *

If adopted, when? *

Valid Passport *

Issuing Country *

Expiry Date *

Passport Number *

Emergency Contact (other than parents) *

Relationship to Applicant *

Emergency Contact Phone *

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: *

Business Phone *

Cell 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) *

Have you been prescribed any medications within the last 12 months? *

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) *

Please list the mental health professionals you have seen in the last 3 years: (Including name, phone, email, professional title, and dates of service) *

If yes, please give the diagnosis, and describe the circumstances and dates. What events precipitated the admissions and what were the outcomes? *

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: *

Send

​Camp Extreme Boys Participant Application 2018

Family Information

Past Summer Program History

Academic History

Medical or Psychological Treatment

References

Camp Extreme Boys Participant Application 2018