REGISTRATION FORM SUMMER 2019 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 This page uses 128 bit SSL encryption to keep your data secure.