Winter Camp 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 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 2011 2012 2013 2014 2015 2016 2017 2018 Contact Info Phone Email Schools School Hebrew School 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 Cost $280 for the week $60 per day Hot Lunch included Please indicate the days your child will attend camp: Monday (December 26, 2022) Tuesday (December 27, 2022) Wednesday (December 28, 2022) Thursday (December 29, 2022) Friday (December 30, 2022) Whole Week 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.
