Printed from JewishDelco.org

About Us Past Events

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:

This page uses TLS encryption to keep your data secure.

More in this section

Past Events

Shavuot Celebration 2015

Simchat Torah

Shabbat In Israel

JLI War on Terror

Chanukah 5776

Shabbat Chinese

Shabbat in One Hour

Purim in the Jungle

Pesach Seder

Shavuot at Chabad

Contact

Subscribe

Donate