Chabad Winter Camp

Child 1*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Gender*

MaleFemale

Sessions ($150 for the week, $50 per day)*

Child 2

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

Sessions ($150 for the week, $50 per dayn)

If you have additional children please contact us.

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?

Emergency Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Relationship*

Pediatrician & Insurance

First NameLast Name

Phone Number

Area CodePhone Number

Insurance

Policy #

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

1. Child/ren’s Information

2. Parent information

3. Emergency Information

4. Payment Information