Dates: June 11-July 4th, 2019
Times: Monday - Friday, 10:00 AM - 4:00 PM
Ages: 5 - 10 years old
Rate: $185/week for Early Bird by May 25, After is $200

Family Information
Family Name Fathers Name Heb Name
Mothers Name Heb Name
Home Phone Home Address City, State, Zip
Fathers Cell # Fathers Work # Fathers Email
Mothers Cell # Mothers Work # Mothers Email
Marital Status Married Divorced Separated Widowed Other
Camper Information
Child #1
Full Name Hebrew Name Called By
Gender Age Birthdate
Child #2
Full Name Hebrew name Called By
Gender Age Brithdate
Health Information
Emergency Contact            
Name   Relationship   Phone
Family Physician          
Name   Address   Phone
Insurance Provider            
Provider   Phone #   Policy/Group

Please list any health problems, medications, or health information the camp needs to know

Please list any allergies
Other Information
Addtl Persons Authorized to Pick Up: Name   Phone #


Payment Information

Total: $
CC Type CC Number
Expiration CVN

Additional Comments (optional):