Enrollment Form
* required field
Camper's Home Address
 
First Parent
Second Parent
    Yes    No
    Both parents    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.)?

Kfar Camping Co., Inc. d/b/a Camp Modin ("Camp Modin") takes reasonable steps to accommodate children with food allergies and gluten intolerances and to identify ingredients that may cause allergic reactions for those with food allergies as well as to instruct our food production staff on the severity of food allergies. Gluten-free options are always available. In addition, Camp Modin labels items with possible allergen-containing ingredients; however, there is always a risk of cross contamination. There is also a possibility that manufacturers of the commercial foods we use could change the formulation of any food product or substitute ingredients at any time, without notice to us. As a result, WE CANNOT GUARANTEE the accuracy of the contents of each food item, or that any particular food product is free of all traces of any particular allergen, or that consumption of a food product will not result in some form of allergic reaction, or that your child will not come into contact with ay allergens. Camp Modin does not guarantee an environment free of allergens.

Additionally, Camp Modin accepts products into our dining services with warning labels on the packaging such as, but not limited to, "manufactured on shared equipment and/or processed in a facility that uses milk, eggs, peanuts, tree nuts, soy, fish, wheat, and gluten". Camp Modin will not assume any liability for adverse reactions to foods consumed, or items your child may come in contact with while attending camp. Parents of campers with food allergies are encouraged to contact the directors, Howard & Lisa Salzberg, at +1.212.570.1600 to discuss food allergy policies and protocols.

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?

Kfar Camping Co., Inc. d/b/a Camp Modin ("Camp Modin") takes reasonable steps to accommodate children with food allergies and gluten intolerances and to identify ingredients that may cause allergic reactions for those with food allergies as well as to instruct our food production staff on the severity of food allergies. Gluten-free options are always available. In addition, Camp Modin labels items with possible allergen-containing ingredients; however, there is always a risk of cross contamination. There is also a possibility that manufacturers of the commercial foods we use could change the formulation of any food product or substitute ingredients at any time, without notice to us. As a result, WE CANNOT GUARANTEE the accuracy of the contents of each food item, or that any particular food product is free of all traces of any particular allergen, or that consumption of a food product will not result in some form of allergic reaction, or that your child will not come into contact with ay allergens. Camp Modin does not guarantee an environment free of allergens.

Additionally, Camp Modin accepts products into our dining services with warning labels on the packaging such as, but not limited to, "manufactured on shared equipment and/or processed in a facility that uses milk, eggs, peanuts, tree nuts, soy, fish, wheat, and gluten". Camp Modin will not assume any liability for adverse reactions to foods consumed, or items your child may come in contact with while attending camp. Parents of campers with food allergies are encouraged to contact the directors, Howard & Lisa Salzberg, at +1.212.570.1600 to discuss food allergy policies and protocols.

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 26, 2019 - Wednesday, August 14, 2019
$13,500
July Session: Wednesday, June 26, 2019 - Sunday, July 21, 2019
$8,100
August Session: Monday, July 22, 2019 - Wednesday, August 14, 2019
$8,100
Optional charge:
Linen & Bedding (including blankets, sheets, pillows, and towels)
$350 per session
Optional programs:
Horseback Riding — open to everyone — $495 per session
JULY   AUG.
Golf — prior experience recommended — $475 per session
JULY   AUG.
Ice Hockey — prior experience required — $475 per session
JULY   AUG.
Figure Skating — prior experience required — $475 per session
JULY   AUG.
Click the name of a program above for more detailed information.
Payment terms:
$2,500 deposit with application
$2,500 by December 15, 2018
Balance by April 15, 2019
Peace of Mind Tuition Insurance

In order to help protect your investment in your child summer camp experience, Camp Modin recommends that families purchase camp travel insurance. Because the Modin tuition deposit is non-refundable, this program provides a variety of levels of coverage, should you need to cancel your enrollment. Our insurance company, AM Skier, recommends the A+ Program Protection through Travmark, and a link to their programs can be found at:

https://www.aplusplans.com/index.php/consumer/portal/MODI11

Mark Ceslowitz of Travmark is happy to speak to you should you have questions about coverage. He can be reached at 917-842-2292 or at mark@travmark.com.

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 $2,500 non-refundable deposit to accompany enrollment; $2,500 due by December 15, 2018; balance due by April 15, 2019. Enrollments may be canceled with written notice through April 15, 2019 for a full refund less the $2,500 deposit fee which is non-refundable. After April 15, 2019, 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, 2018. The Camp strongly recommends that Parent purchase camp travel insurance at https://www.aplusplans.com/index.php/consumer/portal/MODI11 to protect their investment in the Camper’s summer camp experience.

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.

8. Kfar Camping Co., Inc. d/b/a Camp Modin ("Camp Modin") takes reasonable steps to accommodate children with food allergies and gluten intolerances and to identify ingredients that may cause allergic reactions for those with food allergies as well as to instruct our food production staff on the severity of food allergies. Gluten-free options are always available. In addition, Camp Modin labels items with possible allergen-containing ingredients; however, there is always a risk of cross contamination. There is also a possibility that manufacturers of the commercial foods we use could change the formulation of any food product or substitute ingredients at any time, without notice to us. As a result, WE CANNOT GUARANTEE the accuracy of the contents of each food item, or that any particular food product is free of all traces of any particular allergen, or that consumption of a food product will not result in some form of allergic reaction, or that your child will not come into contact with ay allergens. Camp Modin does not guarantee an environment free of allergens.

Additionally, Camp Modin accepts products into our dining services with warning labels on the packaging such as, but not limited to, "manufactured on shared equipment and/or processed in a facility that uses milk, eggs, peanuts, tree nuts, soy, fish, wheat, and gluten". Camp Modin will not assume any liability for adverse reactions to foods consumed, or items your child may come in contact with while attending camp. Parents of campers with food allergies are encouraged to contact the directors, Howard & Lisa Salzberg, at +1.212.570.1600 to discuss food allergy policies and protocols.

By electronically signing my name below, I certify that I have read the above information. I understand the risks set forth above and that my child may be exposed to allergens and injury despite the best efforts of Camp Modin. Without limiting the terms of any other release, I hereby release and discharge Kfar Camping Co., Inc., its officers, directors, shareholders, employees, counselors, and agents from any and all liability or responsibility to my child, myself, or any third party for any and all injuries, including without limitation death, claims, or damages, direct or indirect, that may arises out of or relate to my child's exposure to allergens or consumption of food while at Camp Modin.

9. The terms and conditions set forth in the Camp Modin Get Ready Booklet are incorporated by reference, and I agree that said terms and conditions are as binding as if fully set forth herein.

10. I hereby authorize Kfar Camping Co., d/b/a Camp Modin to charge my credit card for any incidental costs or fees incurred by or on behalf of my child, including without limitation and by way of illustration only, unaccompanied minor fees, prescription costs, co-pays for medical treatment, or damages to Camp property caused by my child. I understand that a receipt will be provided to me on request. If for any reason my credit card cannot be successfully processed, I agree to pay all such charges in full within 7 days of demand, by check, wire, or other credit card.

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.
Use your mouse (on a computer) or finger (on a mobile device) to sign your name inside the box below.
Then click the SUBMIT button.
You must sign your name in the box below in order to submit the enrollment form.