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Dates: August 5 - 16, 2013
Times: Monday - Friday, 9:00 AM - 3:00 PM
Ages: 3 - 7 years old
Rate: $220/week, $50/day

Family Information
Family Name Fathers Name Heb Name
Mothers Name Heb Name
Home Phone Home Address City, State, Zip
Fathers Cell # Fathers Work # Fathers Email
Mothers Cell # Mothers Work # Mothers Email
Marital Status Married Divorced Separated Widowed Other
Camper Information
Child #1
Full Name Hebrew Name Called By
Gender Age Birthdate
Child #2
Full Name Hebrew name Called By
Gender Age Brithdate
Health Information
Emergency Contact
Name Relationship Phone
Family Physician
Name Address Phone
Insurance Provider
Provider Phone # Policy/Group

Please list any health problems, medications, or health information the camp needs to know

Please list any allergies
Other Information
Addtl Persons Authorized to Pick Up: Name Phone #

Payment Information

Total: $
CC Type CC Number
Expiration CVN

Additional Comments (optional):

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