Enrollment Form
* required field
Male   Female
Camper's Home Address
 
Both parents   Father   Mother
Both parents   Father   Mother
First Parent
Second Parent
Emergency Contact
Medical Information
Please answer all questions accurately. The information is confidential and only reviewed by the directors, medical personnel and social worker. Failure to disclose information may lead to dismissal of Camper from Camp, and, in the event of such dismissal, there will be no refund.
1) Has your child received professional counseling (in or out of school) or medication for behavioral/emotional related issues during the last 12 months?

Please elaborate and list any medications:

2) Has your child been diagnosed with Attention Deficit Disorder (ADHD), with or without hyperactivity?

Please elaborate:

3) Does your child take any medications, prescribed or otherwise, either daily or during the school day, for ADHD with or without hyperactivity, focusing or any other reasons?

Please elaborate and list medications:

4) Does your child have any life-threatening, anaphylactic allergies to foods (such as peanuts, tree nuts, sesame, dairy, eggs, coconut, fish, fruits, etc.)?

Please list all food allergies that trigger anaphylactic reactions:

5) Does your child have Celiac Disease or a wheat allergy requiring a gluten free diet?

Please provide specific details on any restrictions, limitations or requirements:

6) Is your child a diabetic?

Please provide specific details on any restrictions, limitations or requirements:

7) Does your child have any other significant allergies or medical conditions we should be aware of?

Please provide specific details on any restrictions, limitations or requirements:

Tuition Fees (All inclusive**)
Please enroll my child for the following session:
Full Season: Wednesday, June 28, 2017 - Wednesday, August 16, 2017
$12,500
July Session: Wednesday, June 28, 2017 - Sunday, July 23, 2017
$7,500
August Session: Monday, July 24, 2017 - Wednesday, August 16, 2017
$7,500
Optional charge:
Linen & Bedding (including blankets, sheets, pillows, and towels)
$325 per session
Optional programs:
Horseback Riding — open to everyone — $495 per session
JULY   AUG.
Golf — prior experience recommended — $450 per session
JULY   AUG.
Ice Hockey — prior experience required — $425 per session
JULY   AUG.
Figure Skating — prior experience required — $425 per session
JULY   AUG.
Click the name of a program above for more detailed information.
Payment terms:
$2,200 deposit with application
$2,200 by January 1, 2017
Balance by April 30, 2017
Payment method for deposit:
  Cash / Check
  Credit Card

Camp Modin accepts checks, Visa, MasterCard, Discover, and American Express. A 3% credit card transaction fee will be assessed on all payments made by credit card.

**Camp tuition is inclusive of laundry service and canteen fees. It does not include transportation costs to and from camp, optional teen trips, specialized programs, Modin Apparel, or medical expenses incurred while at camp. We offer a discount of $200 for a full season enrollment and $100 for a single session enrollment for each subsequent sibling enrolled at Camp Modin for the current year. Camp Modin does offer credits for referrals. Please contact the office for details.

1. The camper ("Camper") and parent/guardian(s) ("Parent") agree to abide by all of the rules and regulations established by Kfar Camping Co., Inc. d/b/a Camp Modin ("Camp") including, without limitation, those relating to enrollment and withdrawl of campers.

2. Payment terms are a $2,200 non-refundable deposit to accompany enrollment; $2,200 due by January 1, 2017; balance due by April 30, 2017. Enrollments may be canceled with written notice through April 30, 2017 for a full refund less the $2,200 deposit fee which is non-refundable. After April 30, 2017, no payments will be refunded. Regardless of payment method, no adjustments, credits, allowances, or refunds will be made for late arrival, early withdrawal, or dismissal of Camper. Payments are non-transferable. No Camper will be allowed to convert from a full season enrollment to a first or second session enrollment after December 1, 2016.

3. The Camp, in its sole discretion, reserves the right to dismiss any Camper whose condition, conduct, influence, or behavior is unlawful, in violation of Camp policy, or is deemed detrimental or unsatisfactory to the Camp, in which case no refunds will be made.

4. This Enrollment Application shall be construed in accordance with and governed by the laws of the State of Maine. Any litigation concerning this Enrollment Application or any claims arising under or in connection with it shall be brought in the District or Superior Court for Kennebec County, Maine, which the parties expressly agree shall be the exclusive venue for any such litigation. The substantive law of the State of Maine will govern such disputes without regard to conflict of law rules. The parties voluntarily and intentionally waive the right to a jury trial in respect of any such litigation. Any individual bringing legal action against the Camp, which action is decided in favor of the Camp, will be responsible for all legal fees, court costs, and out-of-pocket expenses of the Camp, its owners, and employees.

5. Permission is hereby granted for the Camp to use any digital, photographic, video images, audio recordings, or likenesses of Camper taken or produced at the Camp or elsewhere, documenting Camper in Camp activities; and statements, articles, names, music, art, films, and videos created by Camper for promotional purposes and in other Camp related ventures both now and in the future.

6. All children are required to provide proof of health and accident insurance. Parent grants Camper permission to participate in all Camp activities and excursions and understands that accidents and injuries can occur in the course of participation in such activities.

7. The Camp is not responsible for lost, stolen, or damaged personal property of campers.

I have read and accepted all of the terms and conditions set forth above in this Enrollment Application. By typing my name below and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes. You must check the box next to or above this text in order to submit your enrollment form.