Encampment 2010

Application Deadline: Wednesday July 21, 2010

Early Bird Discount Deadline: Friday June 25, 2010

Complete and mail to: NERUSY, 1320 Centre St., Suite 304, Newton, MA 02459

For more information contact: 617-964-8210 /

I understand and agree to the following:

  • "Send-homeable" offenses - the use or possession of alcohol, drugs, tobacco products, or the display of unacceptable behavior, including endangering oneself or the safety of others. If one does occur, I accept responsibility for my child's actions and understand that the Encampment Director will require that I pick up my child immediately. In addition, any USYer found in the possession of drugs or alcohol will be suspended from Regional and International programs for a period of one year.
  • I agree to abide by the USY dress code.
  • I understand that NERUSY no longer provides excess medical insurance and that all medical costs will be submitted to the parents' health insurance company.
  • In case of surgical emergency, I hereby give permission to the physician selected by the Encampment Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child named below. I also give my permission to the physician selected by the Encampment Director to advise and treat my child for any illness or medical condition while he/she is under group supervision.
  • I accept responsibility of payment for loss, damage, or destruction of any property done by my child.
  • Visitors will not be allowed during the week.
  • I must forward a doctor's health certificate to NERUSY, 1320 Centre St., Suite 304, Newton, MA 02459.

I understand that I am fully responsible for payment according to the enclosed payment schedule and that once an application is received any monies paid are NOT REFUNDABLE for any reason, per New England Region Youth Commission Policy. Of course, once any application is committed, full payment is expected under all circumstances.

PARENT/GUARDIAN SIGNATURE: ______Date ______

USYER'S SIGNATURE: ______Grade as of 9/1/10 ______

One of the following:

SYNAGOGUE YOUTH DIRECTOR / ADVISOR / RABBI / YOUTH COMMITTEE CHAIR SIGNATURE:

______

You must have all the required signatures, otherwise your application will be sent back to you!

Encampment 2010

Please fill out all fields. Please write legibly!

NAME:PHONE:

SEX: EMAIL ADDRESS:

USY CHAPTER:

HOME ADDRESS:

CITY: STATE: ZIP:

AGE (as of 9/1/10): GRADE (as of 9/1/10):

BIRTHDATE:

VEGETARIAN (check if ‘yes’)

FOR MACHON ONLY: CIRCLE WHICH DAYS ATTENDING ENCAMPMENT: ALL WEEK

THURSFRI SAT SUN MON TUES WED

___THIS IS MY FIRST NERUSY ENCAMPMENT (check if ‘yes’)

___THIS IS MY FIRST REGIONAL EVENT (check if ‘yes’)

PARENT/GUARDIAN NAME & ADDRESS:

HEALTH INSURANCE CO.:

POLICY #:

IN CASE OF EMERGENCY, PLEASE CONTACT (Other than parent or guardian)

NAME: TELEPHONE:

ADDRESS:

CITY: STATE: ZIP:

Encampment 2010

AMOUNT ENCLOSED (PLEASE CHECK APPROPRIATE AMOUNTS ENCLOSED)

___$435 (EARLY BIRD full payment due BY JUNE 25)

___$225 (minimum deposit due JULY 21 - FINAL PAYMENT OF $225 DUE BY JULY 30)

___$450 (full payment due FROM JUNE 26 - JULY 21)

___$350 (Machon - full payment due JULY 21)

___$60 per day (Machon only - due by JULY 21).

List days attending (the campfire will be either Thurs or Sat. night depending on participation):

___$180 (Machon only from Thurs PM – Sunday)

___$45 Bus fee (to be included with first payment)

___I do not plan to take the USY bus

$______Total Enclosed

NAME: PHONE:

EMAIL ADDRESS:

I am able and willing to lead:

__Weekday Shacharit __Full Birkat Hamazon __Kabbalat Shabbat

__Weekday Mincha __HaMotzi__Shabbat Maariv

__Weekday Maariv __Torah Reading __Shabbat Shacharit

__Hebrew Reading __Haftorah__Shabbat Musaf

__Kiddush__Candle Lighting __Shabbat Mincha

KI TETZE is my Bar/Bat Mitzvah Portion KI TAVO is my Bar/Bat Mitzvah Portion

I am a: ___Cohen ___Levi___Yisrael

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PLEASE RETAIN THE FOLLOWING FOR YOUR INFORMATION

EARLY BIRD SPECIAL: (If postmarked by 6/25) $435.00 (plus optional $45.00 bus transportation)

REGULAR ENCAMPMENT TUITION: (Jr. & Sr. USY) $450.00 (plus optional $45.00 bus transportation)

MACHON TUITION: $350.00 (plus optional $45.00 bus transportation)

MACHON (THURS PM – SUNDAY)$180

MACHON (DAILY RATE)$60 per day

$435.00 FULL "EARLY BIRD” payment due TUES, JUNE 25, 2010 (plus optional $45.00 bus)

$450.00FULL payment due FRIDAY, JULY 21, 2010

$225.00Minimum deposit with application, and optional $45 bus transportation,

due WEDNESDAY, JULY 12 (Or full payment of $450 plus bus)

$225.00 Final payment due FRIDAY, JULY 30, 2010

MACHON (2010 High School Graduates):

$350.00FULL MACHON payment (OR $60 per day / OR $180 for Thurs PM - Sunday)

due WEDNESDAY, JULY 21, 2010