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REGISTRATION FORM SUMMER 2017

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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