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 November 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 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 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 Please write your Child's age Please indicate number of sessions your child will attend camp: 1 week of camp $225 2 weeks of camp $450 3 weeks of camp $675 4 weeks of camp $900 Including lunch First Week, June 20 -June 24 Second Week, June 27 -July 1 Third Week, July 4 -July 8Fourth Week, July 11 -July 15 Please Purchase Camp Logo T-Shirt: $10 each Each camper needs to have at least one XS S M L XL Select Size OPTIONAL: Caps with camp logo are also available for $10 each! One size fits all IMPORTANT • All forms must be completed and submitted before your child begins camp. • I will be paying by: Credit Card Name on Card Credit Card Number Exp 01 02 03 04 05 06 07 08 09 10 11 12 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 CVV Code Notes These fees will only be charged upon acceptance of your child 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.