Online Registration! Winter Camp 2013

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
Hebrew 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

     
           
COST
 

Rate for full session: $350
 December 23 - January 1 (8 days)


Daily Rate: 
$50 (sign up for 5 days and pay $225)
 Monday, December 23

 Tuesday, December 24                                                     
 Wednesday, December 25 
 Thursday, December 26
 Friday, December 27                                                                            
 Monday, December 30

 Tuesday, December 31

 Wednesday, January 1

 

    early bird special -  10%  discount register before November 20
IMPORTANT
All forms must be completed and submitted before your child begins camp.

I will be paying by: Check Mastercard Visa

 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