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

I agree to the terms and conditions above.

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