Camper General Information First Name Last Name Hebrew Name Gender SelectBoyGirl Date of Birth Age Place of Birth Languages Spoken Address City State Zip Phone Cell Phone Synagogue Affiliation Family Information Parent/Guardian A First Name Last Name Address (if different than above) City State Zip Home Phone Work Phone Cell Phone Occupation Business Address Email Title of Position Country of Origin Jewish? SelectYesNo Parent/Guardian B First Name Last Name Address (if different than above) City State Zip Home Phone Work Phone Cell Phone Occupation Business Address Email Title of Position Country of Origin Jewish? SelectYesNo Conversions/adoptions in the family SelectYesNo If yes, please specify Send Correspondence to SelectParent AParent BBoth Child's parents are SelectMarriedDivorcedSeparatedMother DeceasedFather DeceasedSingleDomestic Partners Do Parents share legal custody? SelectYesNo Do Parents share physical custody? SelectYesNo Name of Step-parent/s Siblings of Applicant Name Date of Birth Current School Name Date of Birth Current School Name Date of Birth Current School School Child Currently Attends Name of School Dates of Attendance School Phone Number School Contact Person Name of School Dates of Attendance School Phone Number School Contact Person Application Details Personal References Name Phone Name Phone Δ
