Online Registration! Two-week trip Camp 5774.

Please fill out the form below carefully. When you press submit, this form will be sent to our administration office.

Note: Please use a separate form for each child.

Camper/Parent Information
Name
   First
Middle Last  
Address
   Street
City State
Zip
Date of Birth
    
Contact Info
   Phone
Email
 
Schools
   School
Grade

Child's Mother
   Mother's Name
Hebrew Name Work Phone Cell
Child's Father
   Father's Name
Hebrew Name Work Phone Cell
Emergency Contact Info
   Name
Phone Relationship  
Pediatrician
   Name
Phone    

Email

      
           
Rate and Dates
 

Rate: $300

Dates: July 21 - August 1

 
     
IMPORTANT
•
All forms must be completed and submitted before your child begins camp.
•

I will be paying by: Check Mastercard Visa

$100 is due with registration.  If paying by check, your registration is not complete until we receive the check.

Please charge my card:

Total amount

 Card Number 

  Expiration Date


 Security: The Chabad Center uses technology that encrypts all information from the end-user to the web server. This is known as SSL encryption. In fact we use the highest form of this encryption, 128 bit SSL encryption. Secure pages are identified by the "lock" icon in your browser and by the web address beginning with "https://"


 
 

I know of no reason to restrict applicant's activity and give my permission for
participation in all activities except as specifically noted herein. 

In the event that I cannot be reached in an emergency, I give permission for the physician selected by the camp director to transport, hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. 

I, and on behalf of my child, release and agree not to sue Chabad (including its employees) for any damage, claim or injury that my child may sustain, arising from or relating to any activity or camp experience.

 I have read and agree to all mentioned above

Authorized Name