Chabad Winter Camp

Child 1*

First Name Middle Name Last Name

Birth Date*

Month Day Year

Gender*

Male Female

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

Child 2

First Name Middle Name Last Name

Birth Date

Month Day Year

Gender

Male Female

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

If you have additional children please contact us.

Phone Number*

Area Code Phone Number

Address*

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

Mother's info

First Name Last Name

Work Phone

Area Code Phone Number

E-mail Primary email

Cell Phone

Area Code Phone Number

Father's info

First Name Last Name

Work Phone

Area Code Phone Number

E-mail

Cell Phone

Area Code Phone Number

How did you hear of us?

Emergency Contact*

First Name Last Name

Phone Number*

Area Code Phone Number

Relationship*

Pediatrician & Insurance

First Name Last Name

Phone Number

Area Code Phone Number

Insurance

Policy #

Total

$0.00

I would like to pay today: Full amount 20% 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