Camp Amichai Registration Form 2012 / 5772

Please fax this entire form to the Camp Director at 073 219 7838 or scan and email it to
Please also email a photo with camper’s full name and shevet in the subject line.


Applicant’s Information
Last name in English First name in English Preferred name Shevet

Last name in Hebrew

First name in Hebrew

Hebrew birthday

Teudat Zehut number

OR passport number and expiry date



Date of birth (dd/mm/yy)

Age at start of the camp

Country of birth

Date of Aliyah (if applicable)

Countries of citizenship

Full address (including zip code)

Home telephone

Applicant’s cellphone

Applicant’s e-mail address (please write clearly)

Have you been involved in Bnei Akiva?



If ‘Yes’ please indicate which snif.

Have you previously attended Camp Amichai?



If ‘Yes’ please indicate which year(s).

Have you previously attended other camps?



If ‘Yes’ please indicate which ones.

Your understanding of Ivrit is





Parents’ Information
Father’s name Occupation

Telephone at work



Mother’s name


Telephone at work



School Details
School City Completing grade

Please provide the name of a rabbi, madrich or teacher who can be a reference for the applicant: Full name Cellular

Camp Amichai Registration Form 2012 / 5772
Last name First name Shevet

Page 2

Beit Knesset
Beit Knesset where your family are members City

Health Details
Please list any food allergies or dietary requirements

Please list any medical restrictions, allergies or special requirements

Does the application take any prescribed daily medication? Yes If ‘Yes’ please give details (attach separate sheet if necessary)


Emergency Contact
Full name Relationship to applicant

Home telephone

Work telephone


Other Information
How did you hear about Camp Amichai?

If the applicant prefers to be placed in a group with a friend, please indicate their name(s). (Maximum of 4 people.) 1 2 3 4

If you would you like us to contact your friends to tell them about Camp Amichai, please provide their details here: Name Shevet Email Telephone Name Shevet Email Telephone

The Shvatim
Ending 4th grade Ending 5th grade Ending 6th grade Ending 7th grade Nevatim Nitzanim Maalot Maapilim Ending 8th grade Ending 9th grade Ending 10th grade Ending 11th grade Haroeh Eitan Na’aleh Lehava

Camp Amichai Registration Form 2012 / 5772
Rules and Guidelines

Page 3

Summer camp offers opportunities and experiences that will lead to the growth and development of your child while he or she is having an enjoyable and exciting time. To ensure a positive and safe camping experience, we must have the full cooperation and participation of your child. Please review the following central issues and guidelines before submitting your application form: Campers are expected to act in a mature and respectful manner at all times. Camp is a very active place where campers are required to attend all activities. Campers may not remain in their rooms during activities. Campers must attend all tefillot, meals and activities. Campers should understand that while Camp Amichai offers a relaxed, informal environment, disrespect or vulgar language are not acceptable. Speech and attitudes should be consistent with our educational, religious environment. Respect for madrichim, supervisory staff, fellow campers, environment and camp property is an important part of summer camp. Cleanliness is a necessity. Campers are responsible to take care of their clothes and living quarters. Campers are expected to behave responsibly and safely. This includes avoiding areas which are off limits without proper supervision and authorization. Campers are not permitted to bring any items that present potential danger to others. Boys and girls are forbidden from entering bedrooms of the opposite gender. Physical contact of any kind between boys and girls is not permissible. Visits at times other than the designated hours of visiting day are not permitted. Parents are requested not to arrive on any other day, as visitors will not be allowed into camp. Campers will be held responsible for any damages. Campers will be charged for each incident of graffiti writing on walls, tables or any other camp property. If a camper is unable to hike, to sleep outdoors or to participate in strenuous outdoor activities, the Camp Director must be advised of this in writing before the start of the camp. No camper is permitted to leave the campsite at any time, except on organized, authorized, supervised camp trips. Campers must be sensitive to the security situation in Israel and be particularly attentive to instructions from the camp staff.

Tzniut means dressing and behaving in a way that is fitting with the religious nature of Bnei Akiva. We request that you only send clothes that meet these standards:

Girls are required to wear skirts that cover the knee. Sleeveless tops and capped sleeves are not allowed. Tops should have appropriate necklines and should not rise above the top of the skirt at any time. Shorts, tight fitting skirts and mini-skirts are not allowed. For sports activities and tiyulim, girls will be allowed to wear pants under their skirts. Body piercings other than earrings are not allowed. Any piercings cannot be carried out at camp. It is not permitted to color hair at camp. A white Bnei Akiva shirt and a dark skirt must be worn on Friday night and Shabbat afternoon. Denim skirts or sneakers are not permitted on Shabbat.

Kippot must be worn at all times. Sleeveless tops or undershirts (worn alone) are not allowed. All shorts must reach the top of the knees and cover the body modestly. Earrings or body piercings of any type are not allowed. It is not permitted to color hair. A white Bnei Akiva shirt and dark pants must be worn on Friday night and Shabbat afternoon. Jeans or sneakers are not permitted on Shabbat.

DECLARATION I have read and understood the rules and guidelines and I am willing to abide by them. I am aware that the violation of the rules will lead to serious consequences and possible exclusion from the camp. In such circumstances I am aware that no refund will be given and any outstanding fees will be paid to Bnei Akiva.
CAMPER’S NAME _____________________________________________ PARENT’S NAME _____________________________________________ DATE ________________________________________________________ SIGNATURE ___________________________________________ SIGNATURE ___________________________________________

Camp Amichai Registration Form 2012 / 5772
Parental Consent

Page 4

I am aware that acceptance to the camp is contingent upon submission of all required forms and the registration fee. In addition, I understand that the final acceptance of my child to the camp may be dependent on an interview.

I understand that certain camp activities and transportation carry a risk to participants, including but not limited to: traveling, hiking, swimming, and other activities and opportunities offered by the camp, and I hereby consent to the participation of my child(ren) listed above in such activities. In addition, I consent for my child(ren) to be transported to/from any outside trip or activity for which camp transportation is provided.

I certify that my child has been examined by a physician and found to be in good health and able to participate in all camp activities without restriction. I confirm that my child is registered in a Kupat Cholim (health fund) in Israel or is covered by similar health insurance. I understand that my child(ren) may not attend the camp unless and until the accompanying Health History Form is received by the camp. I undertake to inform the directors prior to camp if my child(ren) has received professional counseling or medication during the last 12 months, including details of such counseling or medication. I understand that failure to do so may lead to dismissal of my child(ren) from the camp, and in the event of such dismissal, there will be no refund. It is my sole responsibility to send any necessary medications with my child(ren) to camp and to advise the camp director accordingly. Furthermore, I hereby authorize the directors of the camp to act on my behalf, according to their best judgment, in any emergency requiring medical attention. By signing below, I understand that I am giving the camp consent to provide and/or procure such medical treatment. In the event that there shall be any need for payment of medical expenses, I agree to cover all such expenses and to reimburse the camp immediately for any payments made for the medical care of my child(ren).

I hereby confirm that I have reviewed the camp rules and regulations together with my child and we agree to abide them. I acknowledge that the camp director reserves the right to suspend or dismiss, without tuition refund and at the director’s sole discretion, any camper who violates camp rules and regulations or whose behavior, condition, conduct or influence is deemed harmful, unsatisfactory or detrimental to himself/herself or to the camp community and environment. In such a case, I will be responsible for arranging the immediate pick-up of my child from the camp. I understand that if my child(ren) does not conduct themselves in accordance with the camp policies and procedures on any trip or activity, he/she may be prohibited from participating in future trips or activities. I agree that any expenses incurred as a result of such disciplinary steps will be my responsibility and further agree that no refund shall be due because of such prohibition from subsequent trips or activities.

I agree that my child(ren) may be photographed or otherwise recorded in any media for the camp’s marketing and promotional purposes, and I consent to such promotional use.

In the event that we have arranged with Bnei Akiva to pay the camp registration or participation fee in installments, we undertake to pay the entire fee in accordance with the agreed installment plan. We acknowledge that we will not be entitled to cancel, delay or change the installment plan without the prior written consent of Bnei Akiva.

CAMPER’S NAME _____________________________________________ PARENT’S NAME _____________________________________________

DATE _________________________________________________ SIGNATURE ___________________________________________

Camp Amichai Payment Schedule 2012 / 5772
Last name First name Shevet

Page 5

It is preferable to complete this form in Hebrew / Please complete a separate form for each camper /



The price of Camp Amichai is 6,150 NIS. Of that, 1,000 NIS must be paid upon application. The balance is to be paid by the end of June 2012. Sibling discount: deduct 180 NIS for each additional child. Discount for siblings Additional deduction (if arranged) . . 1000 .6/2012 . 6,150 : : 180 :

___________ NIS ___________ NIS ___________ NIS

Names of siblings ____________________________________

" Card Name on Card Credit Card No. Expiry Date (MM/YY) Last three digits on back the card Amount of payments








Month to be deducted

Day to be deducted 1st 1st 1st 1st 10th 10th 10th 10th

1 2 3 4


: " . , Acceptance onto Camp Amichai is conditional on full payment, and on participants and parents completing and returning the declaration of accepting the rules and guidelines prior to the start of the program. I agree to the above terms. SIGNATURE / ________________________________________________________ DATE / ____________________________________________

Please fax this form to the Camp Director at 073 219 7838 or scan and email it to : 0732197838

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