Return completed form to: CAMP NEJEDA, P.O. Box 156, Stillwater, NJ 07875-0156 Phone: (973) 383-2611 Fax: (973) 383-9891 www.campnejeda.org Summer and Family Camp 2017 Application CAMPER’S NAME: ____________________________________________________________________________________ BIRTH DATE: ________________________ M F Age when at camp in 2017___ Entering Grade ___ in Sept. 2017 ADDRESS: __________________________________________________________________________________________ _________________________________________________________________ COUNTY: ________________________ PRIMARY CONTACT at the above address: _________________________________________________________________ LAST FIRST M.I. Parent One ________________________________________ Relationship to camper _______________________________ Address (if different) ___________________________________ ________________________________________________ Email ____________________________________________ Employer _______________________________________ Home Phone ______________________________________ Work Phone _______________________________________ Cell Phone ________________________________________ IN EMERGENCY, if parents or guardian cannot be reached, notify: _______________________________________________ Relationship ____________ Cell Phone ______________________ Adults’ Names: _________________________________________________________________________________________ Please complete BOTH SIDES of the application – thanks! Price includes programs, accommodations and food for up to four family members. P rice includes non-refundable $50 registration fee. **additional family members (siblings, grandparents, non-family members, etc.) for $75 each. CITY STATE ZIP STREET APT # FAMILY CAMP: Number of family members attending ___ (adults and children) Children’s Names (check mark indicates those with diabetes): _____________________________________ age _____ _____________________________________ age _____ _____________________________________ age _____ _____________________________________ age _____ Price per Summer Overnight sessions: camper* $1,050 $2,050 $2,050 $2,050 Family Camp session: Days and Nights Dates Price per family of four** June Family Camp September Family Camp Friday through Sunday (2 nights) June 23 to June 25 Saturday through Monday (2 nights) Sept 2 to Sept 4 $950 $950 Please complete both sides of the application and return it with $50 non-refundable registration fee Session One - one week (6 nights) Session Two - two weeks (12 nights) Session Three - two weeks (12 nights) Session Four - two weeks (12 nights) Session Five** - one week (6 nights) Dates July 2 to July 8 July 9 to July 21 July 23 to Aug 4 Aug 6 to Aug 18 Aug 20 to Aug 26 $1,050 Campers Age 7-11 years old 12-15 years old 8-12 years old 13-16 years old 7-16 years old Parent Two ________________________________________ Relationship to camper _______________________________ Address (if different) ________________________________________________ ______________________________________________ Email ____________________________________________ Employer ______________________________________ Home Phone ______________________________________ Work Phone ______________________________________ Cell Phone ________________________________________ *Session Five is open to new campers and campers from Sessions 1-4. Price includes non-refundable $50 registration fee. Price per Summer Day Camp sessions: camper $400 $400 $750*** South Jersey North Jersey Manhattan*** Dates July 10 to July 14 July 24 to July 28 Aug 7 to Aug 11 All Day Camps are ages 6-16. Price includes non-refundable $50 registration fee. *** Patients of Mount Sinai Hospital should contact Camp Nejeda for additional pricing information Price per Extended Programs: camper $225 $200 Spring BFF Weekend (2 nights) Fall BFF Weekend (1 night) Dates May 5 to May 7 Sept 9 to Sept 10 BFF Weekends are ages 6-16.
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Return completed form to: CAMP NEJEDA, P.O. Box 156, Stillwater, NJ 07875-0156Phone: (973) 383-2611 Fax: (973) 383-9891 www.campnejeda.org
PRIMARY CONTACT at the above address: _________________________________________________________________
LAST FIRST M.I.
Parent One ________________________________________Relationship to camper _______________________________Address (if di�erent) ___________________________________
Please complete BOTH SIDES of the application – thanks!
Price includes programs, accommodations and food for up to four family members. P rice includes non-refundable $50 registration fee.**additional family members (siblings, grandparents, non-family members, etc.) for $75 each.
CITY STATE ZIP
STREET APT #
FAMILY CAMP: Number of family members attending ___ (adults and children)Children’s Names (check mark indicates those with diabetes):
_____________________________________ age __________________________________________ age _____
_____________________________________ age __________________________________________ age _____
Price perSummer Overnight sessions: camper*
$1,050$2,050$2,050$2,050
Family Camp session: Days and Nights DatesPrice per
family of four**June Family CampSeptember Family Camp
Friday through Sunday (2 nights) June 23 to June 25 Saturday through Monday (2 nights) Sept 2 to Sept 4
$950 $950
Please complete both sides of the application and return it with $50 non-refundable registration fee
Session One - one week (6 nights) Session Two - two weeks (12 nights) Session Three - two weeks (12 nights) Session Four - two weeks (12 nights) Session Five** - one week (6 nights)
DatesJuly 2 to July 8July 9 to July 21 July 23 to Aug 4 Aug 6 to Aug 18 Aug 20 to Aug 26 $1,050
Campers Age 7-11 years old
12-15 years old8-12 years old
13-16 years old7-16 years old
Parent Two ________________________________________Relationship to camper _______________________________Address (if di�erent) ________________________________________________
______________________________________________
Email ____________________________________________ Employer ______________________________________ Home Phone ______________________________________ Work Phone ______________________________________ Cell Phone ________________________________________
*Session Five is open to new campers and campers from Sessions 1-4.Price includes non-refundable $50 registration fee.
Price perSummer Day Camp sessions: camper
$400$400$750***
South JerseyNorth JerseyManhattan***
Dates
July 10 to July 14 July 24 to July 28 Aug 7 to Aug 11
All Day Camps are ages 6-16.Price includes non-refundable $50 registration fee.*** Patients of Mount Sinai Hospital should contact Camp Nejeda for additional pricing information
Price perExtended Programs:camper $225$200
Spring BFF Weekend (2 nights)Fall BFF Weekend (1 night)
2017 Summer and Family Camp ApplicationContinued from other side
• Summer Camp, Day Camps, and Extended Programs: I hereby apply for admission of the forenamed child to camp. If this child is accepted, I give consent to the administration of insulin and whatever other medical care and advice may be deemed necessary while at camp. In case of emergency, I understand every effort will be made to contact parents or guardians of campers. In the event that I cannot be reached, I hereby give permission to the camp physician and/or camp director to hospitalize, secure treatment for my child, as named, and hereby release the camp from any liability for any accident or injury to said child occurring at camp or on a camp-sponsored trip off the camp site.
• Family Camp: I accept responsibility for my care and the care of my family while at Camp Nejeda.
• Image Release: I give permission for the use of pictures, images or other likenesses of my child and/or family to be used for promotion,educational material or other purpose deemed necessary by the Camp Nejeda Foundation, Inc.
• Cancellations/Refunds: Fees (minus the non-refundable registration fee) will be refunded up until 2 months before the camper's session begins. Within two months of the session, credit will be applied if the camper's spot is able to be filled.
Signature _____________________________________ Date __________ Relationship to Camper __________________
DOES YOUR CAMPER USE AN INSULIN PUMP? YES NO If yes, what brand? _________________________Does camper have any special needs? ______________________________________________________________________
Has camper been away from home before? YES NOHas camper been to Camp Nejeda before? YES NO Has camper been to other camps before? If Yes, where? _______________________________ Where did you learn about Camp Nejeda? _________________________________________________________________
Our program sta� will do all they can to grant bunkmate requests, but they are not guaranteed. Thank you for understanding.
Please complete BOTH SIDES of the application – thanks!
Please accept my tax-deductible donation in support of Camp Nejeda’s programs
Registrationavailable online
after Sept. 1, 2014
PAYMENT INFORMATION: (Check all that apply. Remember to include registration fee in calculations.)
I have enclosed a check/money order or have �lled out the Nejeda Credit Card form (available online)in the amount of $____________ and will pay any balance owed before May 1, 2017.
I am paying the entire balance now. (**Discounts below apply to Summer Camp overnight sessions only.)
Take a discount of $50 if paying the entire balance before December 31, 2016**.
I have enclosed the $50 registration fee and would like to set up a payment plan. (Full payment is due by May 1, 2017). Number of payments (circle) 1 2 3 4 (Full payment is due by May 1, 2017)
Dates: 1______________ 2 ______________ 3______________ 4 _______________I will send my payments by check or money order payable to Camp Nejeda .Please charge my Visa/MC/Discover/AmEx (using Nejeda Credit Card form available online).
I have enclosed the $50 registration fee. Payment will be coming from a third party (other than a parent/guardian).Please include contact information for the party: ___________________________________________________________
I have enclosed the $50 registration fee. I will be applying for Financial Aid .
YES NO
for children and families with diabetes. $ __________Donations cut camp fees in half for every camper and cover 100% of camper fees for those with the greatest need, totaling $600,000 each year.
