Camper/Parent Information
Name
  First
Middle
Last
 
Address
  Street
City
State
Zip
Date of Birth
   
Contact Info
  Phone
Email
 
Schools
  School
Hebrew School Entering Grade:
Child's Mother
  Mother's Name
Hebrew Name Work Phone
Cell
Child's Father
  Father's Name
Hebrew Name Work Phone
Cell
Emergency Contact Info
  Name
Phone
Relationship
 
Pediatrician
  Name
Phone
   

Email

     
           
Select Child's Age Group
Ages 4-6
Ages 7-10  
 
 
Please indicate the weeks your child will attend camp (N/A For Winter Camp):

Week 1- June 25- June 29  Week 2- July 2-6
     
IMPORTANT
All forms must be completed and submitted before your child begins camp.
  With the submission of this form I am paying for: Only Registration Fee
Partial Tuition & Registration Fee Full Tuition & Registration Fee
I will be paying by: Check Mastercard Visa Amex

Card Number

Expiration Date
Cardholder
Name
Total Amount
I have read the camp brochure and application form and agree to the terms stated. I give my child permission to attend all trips, and receive medical care in the case of emergency.
  Date of Application: