Information

Parent(s)/Guardian(s) Particulars

3. Medical Details

This form must be completed in full, by the parents or legal guardian of the applicant, together with their MEDICAL PRACTITIONER. Please note: forms will not be considered if this documentation is not completed and signed accordingly.

1. 
   Please state your medical aid scheme and number and include a photocopy of your membership card, in case the applicant requires emergency medical attention.
   

Medical Aid Scheme:

Medical Aid Number:

Medical Aid Dependant Number:

2. 
   Please indicate previous illnesses the applicant has had:
   

• 
  Chicken pox
  
• 
  Diabetes
  
• 
  Diphtheria
  
• 
  Enteric Fever
  
• 
  German Measles
  
• 
  Measles
  
• 
  Mumps
  
• 
  Poliomyelitis
  
• 
  Rheumatic Fever
  
• 
  Typhoid Fever
  
• 
  Swine flu
  
• 
  Whooping cough
  
• 
  Other___________________
  

3. 
   Please indicate when the applicant has been immunized against the following:
   

NB: Please ensure the applicant has had an anti-tetanus booster within the past five years!
Diphtheria Y / N Year:

MMR Y / N Year:

Polio Y / N Year:

Tetanus: Y / N Year:

Whooping Cough: Y / N Year:

4. 
   Is the applicant on any chronic medication? Please provide full details:
   

_______________________________________________________________________________________________________________________________________

5. 
   For the medical practitioner specifically:
   
   1. 
      How long have you been the applicant’s medical practitioner? __
      
   2. 
      Are there any condition(s) that the applicant is suffering from (e.g. epilepsy), and, if applicable, are there any specialists treating the said condition? (Please provide contact details of the specialist)
      

_____________________________________________________________________________________________________________________________________

3. 
   Does the applicant suffer from asthma/allergies (e.g. bee-stings, dust)? Include details and prescribed treatment.
   

___________________________________________________________________________________________________________________________________________________________________________________________________________

4. 
   Has the applicant ever had fits, black outs or fainting spells? (Include details and, where possible, diagnosis)
   

_______________________________________________________________________________________________________________________________________

5. 
   Is the applicant allergic to any drugs (e.g. penicillin)? Please provide full details:
   

___________________________________________________________________________________________________________________________________________________________________________________________________________

6. 
   Are there any reasons, physical or emotional, that the applicant should have extra attention on a long hike?
   

_______________________________________________________________________________________________________________________________________

7. 
   Are there any additional precautions that should be taken with regard to the applicant’s health at camp?
   

_______________________________________________________________________________________________________________________________________

8. 
   Is the applicant on any maintenance therapy? Please provide details:
   

_______________________________________________________________________________________________________________________________________

9. 
   Does the applicant suffer from any physical/emotional conditions that may be aggravated at camp?
   

_______________________________________________________________________________________________________________________________________

10. 
    Does (has) the applicant ever suffer(ed) from any physical disability (e.g. partial paralysis, orthopaedic, etc.)?
    

_______________________________________________________________________________________________________________________________________

11. 
    Has the applicant undergone any surgical procedures in the past 12 months? Y / N
    

If yes, please attach report

I have personally examined the applicant and in my opinion s/he should/should not be allowed to attend Netzer Machaneh. (Please delete as necessary)

Practitioner’s name: Signature:

Tel (practice): Tel (emer.)

Date:

4. Financial Details

COST BREAKDOWN		DETAIL		CHARGE
Early Bird Camp fee Basic Camp fee		Before 8^th October – R4 700 After 8^th October – R5 000		R
--ADD--
Transport		Cape Town – R400 Durban - R1 700 Johannesburg – R1 700		R
Late arrival / Early departure		Logistical fee – R200		R
Late application		After 7^th November – R200		R
Assist-A-Camper Appeal		R100  R300  R600  R1 000  R3 000  R5 000  R6 600  10 000  Other 		R
**Offset your carbon foot print		Plant a tree with the JNF – R50		R
Buy a Netzer CD		Support our fundraising initiative - R30		R
Netzer Chultzah KESHET ONLY		R150		R
--SUBTRACT--
Sibling Discount		See page 8		R ( )
Friend Discount		See page 8		R ( )
--TOTAL--
TOTAL				R

PAYMENT
Method of payment: (Please tick)		Cheque 	EFT/Direct Deposit 	Cash 

**Please consider offsetting the carbon footprint of your child’s camp experience: the travel to camp, the transport to special events and daily activities. Netzer is dedicated to recycling and reducing its carbon footprint as much as possible while on camp. Do your part and plant trees to offset what we can’t reduce. For R50, the Jewish National Fund will plant a tree in Israel or in South Africa and your tree will absorb carbon for approximately 70 years- having a positive impact on our environment! Go green this summer

Any forms handed in after the due date will be charged a late fee of R200 per person.

Late forms may compromise your child’s participation in Machaneh, and seriously inconveniences Netzer South Africa.

Refer to page 19 for information regarding where to return camp forms.