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Chabad Winter Camp

1. Child/ren’s Information
Child 1*
First NameMiddle NameLast Name
Birth Date*
MonthDayYear
Gender*
MaleFemale
Sessions ($150 for the week, $50 per day)*
Full Week 1MondayTuesdayWednesdayThursdayFriday
Child 2
First NameMiddle NameLast Name
Birth Date
MonthDayYear
Gender
MaleFemale
Sessions ($150 for the week, $50 per dayn)
Full WeekMondayTuesdayWednesdayThursdayFriday
If you have additional children please contact us.
2. Parent information
Phone Number*
Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's info
First NameLast Name
Work Phone
Area CodePhone Number
E-mailPrimary email
Cell Phone
Area CodePhone Number
Father's info
First NameLast Name
Work Phone
Area CodePhone Number
E-mail
Cell Phone
Area CodePhone Number
How did you hear of us?
3. Emergency Information
Emergency Contact*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship*
Pediatrician & Insurance
First NameLast Name
Phone Number
Area CodePhone Number
Insurance
Policy #
4. Payment Information
Total
$0.00

I would like to pay today: Full amount20% minimum: $0.00 $

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Agreement*
I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid. I give Chabad permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit.
General comments
Should be Empty:

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Bar/Bat Mitzvah Lessons

Kids in the Kitchen

Chabad Winter Camp

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