Camper Information
*First Name
*Last Name
Hebrew Name
*Gender
*Date of Birth
*Address
*City
*State
*Zip
*Home Phone
*School
*Grade
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
Have there been adoptions or conversions in the family?
If yes, please explain
Medical Information
Physician Name
Physician Phone
Insurance
Insurance Number
Allergies
Medical Note
Emergency Information
Name Phone # Relation
*Emergency 1
Emergency 2
Emergency 3
Enrollment Options / Tuition & Fees

Tuition fees: $1,125 for all 5 weeks or $225 per week .
Registration fee: $50
(includes 2 daily snacks and camp t-shirt).


If qualified in advance by the office, scholarship rate should be selected. To contribute to the scholarship fund, please contact our office.

Sessions
All Weeks





*Tuition
AM Extended Care
PM Extended Care
Total Amount:

The tuition fees (above) will be charged upon acceptance of your child.
Registration fee will be charged when submitting this form.

Payment Information
The tuition fees (above) will be charged upon acceptance of your child.
Registration fee will be charged when submitting this form.
Registration Fee
*Payment Type
*Card Number
*Expiration Date
*Security Code
Use my Contact Information
*Name on Card
*Billing Address
*Billing Zip code

I agree to the terms and conditions above

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