To register, please fill out carefully. Tuition for camp is $180 per week.

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
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
Please indicate if you will need before care or after care: (additional fee)

Before Care 8:00 - 9:00AM After Care 3:00 - 4:00 PM
IMPORTANT
•
 I will be paying by: Check Mastercard Visa Amex

Card Number

 Expiration Date (mm/yy)
Cardholder
Name
 Total Amount
I give my child permission to attend all trips, and receive medical care in the case of emergency.
Date of Application: