Camper Information
*First Name
*Last Name
Hebrew Name
*Gender
*Date of Birth
*Address
*City
*State
*Zip
Country
*Home Phone
*School
*Grade
Note
Parent Information
Father
*First Name
*Last Name
Work Phone
*Cell Phone
*Email
Mother
*First Name
*Last Name
Work Phone
*Cell Phone
*Email
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

Please choose enrollment options

Sessions
All Sessions




*Tuition
AM Extended Care
PM Extended Care
Total Amount:

These fees will only be charged upon acceptance of your child

Payment Information
Only registration fee will be charged at this time.
Registration Fee
*Payment 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

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