CAMPER NAME:
SESSION:
GRADE FALL 2015:
EMMA KAUFMANN CAMP
CAMPER INFORMATION FORM
OFFICE USE ONLY:
DATE RECEIVED:
PLEASE COMPLETE THE ENTIRE FORM AND RETURN IT TO THE EKC OFFICE
BY FRIDAY MAY 29, 2015
CAMPER’S BIRTHDATE:
AGE AT CAMP:
BIRTHDAY AT CAMP?
ADDRESS WHERE CHILD LIVES:
HOME PHONE NUMBER:
EMAIL ADDRESS:
T-SHIRT SIZE (PLEASE CIRCLE): YOUTH: S
M
L
OR
ADULT:
S
M
L
XL
XXL
HOW MANY YEARS HAS YOUR CHILD ATTENDED EKC (INCLUDING THIS SUMMER)?
CHILD LIVES WITH (CHECK): MOTHER
FATHER
BOTH
OTHER
PARENT INFORMATION:
PARENT NAME:
EMAIL:
ADDRESS:
HOME PHONE:
WORK PHONE:
OCCUPATION:
EKC ALUMNI? (PLEASE CIRCLE): YES
CELL PHONE:
EMPLOYER:
NO
CAMPER YEARS:
PARENT NAME:
STAFF YEARS:
EMAIL:
ADDRESS:
HOME PHONE:
WORK PHONE:
OCCUPATION:
EKC ALUMNI? (PLEASE CIRCLE): YES
CELL PHONE:
EMPLOYER:
NO
CAMPER YEARS:
STAFF YEARS:
DOES YOUR CAMPER HAVE ANY SIBLINGS/RELATIVES ATTENDING CAMP?
NAME
GRADE
NAME
GRADE
NAME
GRADE
PICTURE OF CAMPER: PLEASE ATTACH (WITH STAPLES)
A CURRENT PHOTGRAPH OF YOUR CHILD WITH HIS/HER NAME
CLEARLY PRINTED ON THE BACK OF THE PICTURE.
MANDATORY
PLEASE ATTACH A PHOTOGRAPH
OF YOUR CHILD HERE. IT HELPS
OUR STAFF TO BECOME
FAMILIAR WITH YOUR CHILD
BEFORE THEY ARRIVE AT CAMP.
THANK YOU.
BUNK-MATE PREFERENCE
Please list bunk-mate preferences following these guidelines:
1) List MAXIMUM
of two (2) names
2) Make sure names listed are going to EKC during the same session as your camper
3) Make sure names listed are in the same grade and camp unit
4) EKC will do everything possible to honor at least one request
5) Please have a conversation with your child before making the request below. Many times, campers want one thing while the
parent wants another. It is important that both you and your child agree with the choices below so as to alleviate all confusion.
PLEASE NOTE:
1. The only bunking requests considered are the names on the two lines below. We cannot guarantee any more than these two.
2. Please communicate with us directly, by phone, if there is someone who your child may not want to bunk with.
3. If you do not write a name in the space below, we will bunk your child according to where we best see him/her fitting in the
camp community.
4. The Camp Director reserves the right to make final determinations on all bunking assignments. Bunking requests received
after the due date may not be honored.
First Session/Sabra Aleph/Kineret Aleph:
My child would like to bunk with:
Second Session/Gesher:
My child would like to bunk with:
(1) Name:__________________________ Grade (as of 9/15): _____________
(2) Name:__________________________ Grade (as of 9/15): _____________
(1) Name:__________________________ Grade (as of 9/15): _____________
(2) Name:__________________________ Grade (as of 9/15): _____________
First Experience/Specialty Week:
My child would like to bunk with:
(1) Name:__________________________ Grade (as of 9/15): _____________
(2) Name:__________________________ Grade (as of 9/15): _____________
Please use the following space to share any additional concerns in regards to bunking:
LIFE AT SCHOOL
1)Is your child in his/her appropriate grade based on age?
If no, did your child skip a grade? _______________
(Please explain)
was your child held back a grade?
2) Does your child require any special attention at school?
(Please explain)
LIFE WITH FRIENDS
1) What are your child's interests? (outside of school)
2) Does your child make friends easily?
3) What ages are your child's friends?
4) Please list groups, activities or programs that your child belongs to or has participated in:
LOOKING AHEAD TO CAMP
Please be as detailed as possible. This information is shared with your child’s madrichim (counselors).
1) Do you have any special concerns about your child?
2) Have any significant events occurred in your family within the last few years that may affect your child during his/her
experience at camp?
3) Does your child have any fears or concerns? (Fear of heights, water, overnights, etc.)
4) Do you foresee any problems with sleeping habits or bed wetting during camp?
5) Who encouraged your child to attend camp?
6) Why did you choose the session(s) you selected:
_____ Fit with vacation time
_____ Cost
_____ Length of Session
_____Other
7) Has your child attended a camp before? ___________ (If yes, please fill in the information)
Name of Camp: ________________________ Day ( ) or Overnight ( )
Name of Camp: ________________________ Day ( ) or Overnight ( )
Name of Camp: ________________________ Day ( ) or Overnight ( )
8) Were these experiences positive or negative?
9) How does your child feel about coming to EKC?
10) How do you think your child will react to the separation from your family?
Years: _____________
Years: _____________
Years: _____________
11) How does your child react to limits set by others?
Always cooperative: _____
Sometimes resists, but goes along: _____
Please explain:
12) How would you rate your child’s swimming ability?
___Poor
___Fair
___Good
Resists: _____
___Excellent
13) Does your child possess an American Red Cross swim level card? ____________If so, what level?
14) What camp activities are of most interest to your child? ___________________________________________________
15) Are there any camp activities or aspects of camp that are of concern to your child?
16) Do you have any concerns about your child’s physical or emotional limitations while at camp?
17) Does your child need help in dressing, grooming, or care of possessions?
18) Does your child have any concerns about showering, dressing or undressing in front of others?
19) What are your child’s eating habits?
20) What are the goals you have set with your child for this summer?
21) In the discussion of Jewish topics and participating in services and Jewish program, how will your child respond?
Please use the following space to share ANY OTHER IMPORTANT INFORMATION that we may need to know about your
child while at camp:
CAMPER NAME:
SESSION
GRADE (Fall 2015)
Camper Confidential
Return to:
Emma Kaufmann Camp
5738 Forbes Avenue
Pittsburgh, PA 15217
Parent/Guardian completing this form (please print):
The following questions deal with confidential material. This material is reviewed initially by the EKC Administrative Team and
kept in a separate file. If there are any concerns regarding this information, please feel free to call the EKC office. Providing
appropriate information will help your child at camp.
Has your child been in therapy? _____Yes _____No
Diagnosis:
Dates of treatment:
Brief Explanation:
Name of Therapist:
Are there any special goals you have for your child that you have not shared with him/her? (explain)
Will your child be taking any psychotropic medication during camp? (If applicable, please list any special instructions)
Has your child had any illness in the past that might worry him/her?
Are there any other issues you want us to know about your child that might have an impact upon his/her behavior?
It is camp policy for this information to be read by the EKC Administrative Staff. In the best interest of your camper, we may
recommend that this information be shared with your camper’s Unit Head and/or Counselor, presented by the Health and
Wellness Director. We give the EKC Director or their designee permission to use the contained information to serve the best
interest of my child as deemed by the EKC Director or designee. We further give permission for EKC to use photographs or
video of my child for use by the camp to post on their private website or use for promotional or recruitment purposes. A copy of
this form is acceptable to be used in place of original.
Signature of Parent/Guardian
Date