2025 CHHS Summer Camp Madriche Application

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Once you've logged in, enter your CHILD'S NAME in the box above the red arrow.
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CHHS (Camp Har HaShem) Summer Day Camp relies on volunteers and helping hands like you to deliver the best possible camp experience for our young campers! We thank you for your application and willingness to volunteer! We know that when we have Madrichim who are really invested and excited about camp, that energy spreads to the campers! So we hope that you are filling this out because you really want to spend a week (or two) helping younger campers fall in love with camp, being Jewish, and being together doing fun things!

This year there will be two sessions of camp: June 2-6 & June 9-13. You can apply to help for one, or both sessions! Madriche hours are 8:30-3:30 (camp hours are 9-3)

Thanks for filling out this application - some parts are for you to fill out on your own, while the bottom section you might need some help from a parents (insurance cards and immunization forms), We will review all applications reach out to you by May 15th.

CHHS Madriche Application deadline is May 9. No application will be accepted after the deadline.

* First Name

* Last Name

* Birthday

Preferred pronouns:

* Address

* City

* State

* Zip Code

* Applicant's Cell Phone

* Applicant's Email

* Parent Email

* Session(s) you would like to work:

Session #1: June 2-7Session #2: June 9-13Both sessions, if possible

* Entering Grade (2025-2026 School Year)

* T-Shirt Size

* Do you have any allergies?

* Please list any and all allergies that we should be aware of here:

Please tell us about any medications you will take during camp -- even if you can take the medication independently, Har HaShem needs to know.

If we may need to administer medication, please complete the form below, have it signed by your doctor and return it to the Har HaShem Lifelong Learning office or email to our Education & Bet Mitzvah Coordinator, Karli, at ka@harhashem.org by May 20.

Medical Release Form

Please list any and all medications that we may need to assist with while attending camp here (with directions if necessary)

* CHHS Madrichim hours are 8:30 am - 3:30 pm. Please list any schedule conflicts you might have.

* Please list your school and any special classes or extra-curricular activities that would aid in your ability to contribute in a classroom setting as a Madriche.

* Please share your religious education, youth groups or experience in Jewish camps here.

* Please share why you would like to be a part of CHHS this Summer.

PARENT INFORMATION

* Parent 1 Name:

* Parent 1 Email:

* Parent 1 Phone Number:

Parent 2 Name:

Parent 2 Email:

Parent 2 Phone Number:

Emergency Contact

If we are unable to reach you or another adult listed above, provide information of another adult we can contact in case of an emergency.

* Emergency Contact Name:

* Emergency Contact Phone:

* Relationship:

INSURANCE INFORMATION

* Medical Insurance Provider

* Name of Policy Holder

* Plan/Group Number

* Policy Number

* Child's Physician

* Physician's Phone Number

Immunizations

* Please upload either proof of immunization OR the immunization medical exemption form here. Please note that both of these documents require a signature from your child's doctor.

* * By checking this box I am stating that my child will join you each day at camp only if they are not feeling sick. If they are feeling unwell, they will stay home.

* By checking this box I am stating that my child will join you each day at camp only if they are not feeling sick. If they are feeling unwell, they will stay home.

Permissions & Releases
Please read the information in the sections below carefully and mark your acceptance as necessary.

Emergency Information / Permission to Seek Treatment

If and when a child requires medical attention, Har HaShem personnel will make every effort to reach a parent or guardian. If we are unable to reach a parent or guardian, the following instruction will remain in force unless revoked by the parent or guardian:

I hereby authorize Congregation Har HaShem or its authorized representative to call my child’s physician (or another physician) for necessary care for my child in case of emergency. I agree to pay all expenses incurred. This authorizations shall remain effective from June 1, 2025 – May 31, 2026.

I further authorize Congregation Har HaShem or its authorized representative to consent to any x-ray examination, anesthetic, medical or surgical diagnoses or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician or surgeon, whether at the said physician’s office or licensed hospital.

I give this authorization in advance of any specific examination, diagnosis, treatment or hospital care being required, and in order to provide authority and power on any and all such examinations, diagnoses, treatments or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable.

* I grant Har HaShem the right to seek treatment for this child.

I grant Har HaShem the right to seek treatment for this child.

Emergency Release / Assumption of Risk

Parents and guardians, jointly and separately, release Congregation Har HaShem, its officers, agents, and employees from all liability for injuries, illness or property damage resulting from my family/child’s participation in Youth Education Programming and all Har HaShem sponsored activities and agree not to make any claim or demand against them for any or all losses or damages to student/family’s person or property. I have completed the above learning and medical information to the best of my knowledge. I have read all of the above and agree to abide by it.

* I release Har HaShem from liability.

I release Har HaShem from liability.

Photography Release

By completing this registration, I hereby give consent for photographs, film, video or sound recordings to be taken of anyone in my family at Congregation Har HaShem or at a Congregation Har HaShem sponsored activity during the 2025-26 school year or summer camp period (June 2025), and I further consent that such photographs/recordings can be used in publications, promotional materials, news releases, film, video, websites or sound productions as directed and approved by Congregation Har HaShem.

If you do not wish for your child's image to be used, please indicate in writing by emailing Karli at ka@harhashem.org by Monday, May 20, 2025 for camp, or August 15, 2025 for the school year.

* I have read and accept the photography release.

I have read and accept the photography release.

Sat, February 22 2025
24 Sh'vat 5785