Registration »

Camper General Information

First Name

Last Name

Hebrew Name

Gender

Date of Birth

Age

Place of Birth

Languages Spoken

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell Phone

Synagogue Affiliation

Family Information

Parent/Guardian A

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Occupation

Business Address

Title of Position

Country of Origin

Jewish?

Parent/Guardian B

Name

First Last

Guardian Lives at a Different Address Than Above

Guardian Lives at a Different Address

Parent/Guardian B's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Occupation

Business Address

Title of Position

Country of Origin

Jewish?

Additional Family Info

Conversions/Adoptions in the family

Please specify

Send Correspondence to

Child's parents are

Do parents share legal custody?

Do parents share physical custody?

Name of step parents

School Child Currently Attends

Name of School

Dates of Attendance

School Phone Number

School Contact Person

Application Details

Personal References

Name

Phone

Name

Phone