Online Registration! Please fill out the form below carefully. When you press submit, this form will be sent to our administration office. Note: Please use a separate form for each child. Camper/Parent Information Name First Middle Last Address Street City State Zip Date of Birth Select Month Jan Feb March April May June July August Sept Oct Nov December Select Date 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select Year 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 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 10-12 Ages 3-4 Ages 4-9 Ages 2-3 Please indicate number of sessions your child will attend camp: Full Season 1 Session 2 Sessions 3 Sessions 4 Sessions 5 Sessions 6 Sessions IMPORTANT • All forms must be completed and submitted before your child begins camp. • I will be paying by: Check Mastercard Visa 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: This page uses 128 bit SSL encryption to keep your data secure.
