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 Hebrew Name Address Street City State Zip Date of Birth Select Month Jan Feb March April May June July August Sept Oct Nov December Select Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 Boy Girl parent Contact Info Phone Email Session: Full 1st 2nd Schools School Child's Mother Name Cell Phone Work Child's Father Name Cell Phone Work Persons authorized to pick up camper other then parents Name Phone Number Is your child allowed to go home alone Emergency Contact Info Name Phone Relationship Emergency Contact Info #2 Name Phone Relationship Medical/Health Information Medication Medication that your child takes regularly: Will this medication need to be dispensed at camp? Yes No If yes please explain Health Issues Special dietary needs or restrictions: Any recent surgery or serious illness: List any allergies (food or medication) Swimming Can your child swim in a regular size adult pool General Information: Camper Info Camper’s strong likes and dislikes: Camper makes friends: Easily Fairly well With difficulty How does your child feel about going to camp this summer? What is the most important thing that you would like us to know about your child? Anything else you would like us to know? T-Shirt Info I would like to buy 0 1 2 3 4 5 T Shirts at €10.00 a T Shirt T-shirt size 6-8 10-12 14-16 Adult S Adult M Adult L Actual shirt sizes run small (e.g. if you need a 10-12 size order 14-16 etc.) Payment Information: Your registration will be confirmed after the payment is received . Please make a payment of € 150 per week to: Suomen Chabad Lubavitch FI32 1200 3000 0644 02 Comments: This page uses 128 bit SSL encryption to keep your data secure.
