Camp Application Form

Child's Info

Name*

First Last

Hebrew Name*

Gender*

Male
Female

Birthdate*

Has your child ever been evaluated or received services? (Speech, Occupational, Physical, Social, Emotional)

Yes
No

If yes, explain:

Mother's Info

Name*

First Last

Hebrew Name*

Occupation*

Cell Phone*

Email*

Father's Info

Father's Name*

First Last

Hebrew Name*

Occupation*

Cell Phone*

Email*

Contact Info

Home Phone

Address*

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

Family Info

Is the Mother of the child Jewish?*

Yes
No

Is the Father of the child Jewish?*

Yes
No

Are there any conversions in the family?*

Yes
No

Does the child live with both natural parents?*

Yes
No

Marital Status of Parents*

Program Selection

* All children in the 3 yr old group must be fully toilet trained before camp begins.

Program*

2 yr old group. (child must turn 2 before Oct. 1, 2025.)
3 yr old group. (child must turn 3 before Oct. 1, 2025.)
4 yr old group. (child must turn 4 before Oct. 1, 2025.)

Full Name*

First Last

How did you hear about us?*