Camper Information

*Last Name

*First Name

Hebrew Name

*Gender

*Date of Birth

*Address

*City

*State

*Zip

Country

*Home Phone

*School

*Grade Entering Aug 2020 (E2, E3, E4, K - 2 digits only please)

Note

Medical Information

Physician Name

Physician Phone

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

Marital Status

Emergency Information

Name Phone # Relation

*Emergency 1

Emergency 2

Enrollment Options / Tuition & Fees

Please choose enrollment options

Sessions
All Sessions






*Tuition

PM After Care (3:30- 5:00)


Total Amount:

Payment Information

You will be charged a $75 non – refundable deposit which will be applied to the Registration/Security Fee.

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