*Last Name
*First Name
Hebrew Name
*Gender Male Female
*Date of Birth mm/dd/yyyy
*Address
*City
*Province
*Postal Code
*Home Phone
*School
*Grade
Note
*Physician Name
*Physician Phone
*Medicare Number
Allergies
Medical Note
Title --Select Title-- Mr. Dr.
*Work Phone
*Cell Phone
*Email
Title --Select Title-- Mrs. Ms. Dr.
*Marital Status --Select -- Married Divorced Separated Single
Name Phone # Relation
*Emergency 1
Emergency 2
Please choose enrollment options
*Which Program? --Select-- Regular Program (ages 5-10) Pioneer Program (ages 11-13)
Extended Care --Select-- Early & After Care
Swimming Lessons --Select-- Half-hour Weekly
Lunch --Select-- Hot Lunch
Total Amount:
Only the registration fee of $100 will be charged at this time. The balance will be charged on June 1 2013.
Card Type --Card Type-- Visa MC Amex
*Card Number
*Expiration Date --Month-- 01 02 03 04 05 06 07 08 09 10 11 12 --Year-- 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038
*Security Code
Use Information above
Name on Card
*Billing Address
*Billing Postal Code
Parent or Guardian gives permission to have camper participate in all Camp activities and to be taken on all out-of-camp trips authorized by the Camp. Pictures of campers will be put up on our website. In case of medical emergency, Camp staff have permission to treat camper as deemed appropriate.
I agree to the terms and conditions above
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