Winter Camp - Staten Island

Our camp caters to Jewish children studying in public schools across Staten Island. we offer daily arts and crafts; sports and trips, alongside healthy nutritious meals twice daily. Your child will make new friends and be proud to be a Jew!
We begin at 9:30 every morning through 3:30 P.M., transportation is available to and from camp for an extra cost of $15 per day. 

 *Scroll down the page to fill out the form

Mid Winter 2021 (1).jpg

* Denotes required field

 
Child Information
First Name*
Jewish Hebrew Name
Last Name*
Boy  Girl 
Date of Birth (MM/DD/YYYY)*
Address/City/State/Zip*
Home Phone Number*
Mother's Name*  
Mother's Cell*
Mother's Work Phone
Mother's Email*
Father's Name*
Father's Cell*
Father's Work Phone
Father's Email*
P.S. Number*
Grade*

Were there any conversions and/or adoptions in the family?*
 If yes, please explain
Is mother Jewish by birth?*  Yes   No
Is father Jewish by birth?*  Yes   No
Would You Like To Register Multiple Children*
 If registering more than one child, please call the office at 718-735-0215 for our 'Sibling Discount'
  Yes   No
Child #2
First Name
Jewish Hebrew Name
Last Name
 Boy  Girl
Date of Birth (MM/DD/YYYY)
P.S. Number
Grade
Child #3
First Name
Jewish Hebrew Name
Last Name
BoyGirl
Date of Birth (MM/DD/YYYY)
P.S. Number
Grade
Medical Information

Does your child have any allergies or medical conditions?*                    If yes, please explain
Emergency Contact Person*
Emergency Contact's Phone Number*
Child's Doctor*
Doctor's Phone Number*
I give permission for my child to be photographed or videoed as part of his/her and other children's enjoyment, and for possible use in advertising and promotions.
Payment Information
Released Time Mid Winter Camp   $160.00
Home Pick-up and Drop-off   $60.00 
Method of Payment*  
Credit Card Number
Expiration Date
CVV
Name on Card

Checks can be made out to:

Released Time Program
824 Eastern Parkway
Brooklyn, N.Y.
11213
I heard about Released Time Mid Winter Camp from
Comments

 

By submitting this form, I agree to the following terms and conditions:

I grant permission for my child to participate in all activities, including swimming and trips away from the grounds.

I agree that my child may be photographed, and their pictures may be used in future camp promotional materials, including, but not limited to the brochure and the Released Time website.

Released Time is not responsible for personal property brought to Released Time.

If the child’s conduct is harmful to the best interests of Released Time, the child may be dismissed at the sole discretion of the Director with no refund nor reduction of fee.

I hereby give my approval for my child’s participation in any and all activities prepared by Released Time during the selected time.

In exchange for the acceptance of said child’s candidacy by Released Time, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Released Time. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said child, I hereby waive all claims against Released Time. Including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball, soccer and swimming. 

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Released Time, and its affiliates including Directors, Staff, and Assistants to provide the needed emergency treatment prior to the child’s admission to the medical facility. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

BY ACKNOWLEDGING AND SIGNING YOUR NAME AND INITIALS BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Name   Initials