Camper Information

*Last Name

*First Name

Hebrew Name

*Gender

*Date of Birth

*Address

*City

*State

*Zip

Home Phone

*School

Grade

Note

Medical Information

Allergies

Medical Note

Parent Information
Father

Title

First Name

Last Name

Work Phone

Cell Phone

Email

Mother

Title

First Name

Last Name

Work Phone

Cell Phone

Email

Have there been adoptions or conversions in the family?

If yes, please explain

Emergency Information

Name Phone # Relation

Emergency 1

Emergency 2

Emergency 3

Enrollment Options / Tuition & Fees

Please choose enrollment options

Sessions
All Sessions

*Per session price


Total Amount:

These fees will only be charged upon acceptance of your child

Payment Information

An invoice will be send to you, with all discounts applied

Registration Fee

Card Type

Card Number

Expiration Date

Security Code

Use Information above

Name on Card

Billing Address

Billing Zip code

I agree to the terms and conditions above.

secure