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REGISTRATION FORM SUMMER 2016

Family Information

Family Name

Address

Street

City

Zip

Contact Info

Phone

Email

Mother

Mother's Name

Hebrew Name (optional)

Work Phone

Cell

Father

Father's Name

Hebrew Name (optional)

Work Phone

Cell

Emergency Contact Info

Name

Phone

Relationship

Name

Phone

Relationship

Pediatrician

Name

Phone

We would like to apply for a scholarship.

Yes

No

Would you be interested in transportation to and from camp?

Yes

No

Information Camper #1

Name

First Name

Gender
Date of Birth:


Schools

School

Entering Grade:


Quick Health Notes

Medication

Allergies

Health Problems or Disabilities

Does your child require a booster seat according to the law?

Yes

No

Information Camper #2

Name

First Name

Gender

Date of Birth:

Schools

School

Entering Grade:


Quick Health Notes

Medication

Allergies

Does your child require a booster seat according to the law?

Yes

No

Information Camper #3

Name

First Name

Gender

Date of Birth:

Schools

School

Entering Grade:


Quick Health Notes

Medication

Allergies

Health Problems or Disabilities

Does your child require a booster seat according to the law?

Yes

No

Information Camper #4

Name

First Name

Gender

Date of Birth:

Schools

School

Entering Grade:


Quick Health Notes

Medication

Allergies

Health Problems or Disabilities

Does your child require a booster seat according to the law?

Yes

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