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): This page uses 128 bit SSL encryption to keep your data secure.
