JKC CAMP - SUMMER 2023 - ChabadNeshama.com

Full Name*

First Name Last Name

Hebrew Name

Age*

Birth Date*

Month Day Year

School*

Grade Completing*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Area Code Phone Number

Child's Cell Phone

Area Code Phone Number

Child's E-mail

Name of Sibling 1

First Name Last Name

Age of Sibling 1

Name of Sibling 2

First Name Last Name

Age of Sibling 2

Father's Name

First Name Last Name

Father's Religion

Father's Occupation

Father's Business Name

Father's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's E-mail

Father's cell

Area Code Phone Number

Father's Facebook

Mother's Name

First Name Last Name

Mother's Religion

Mother's Occupation

Mother's Business Name

Mother's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's E-mail

Mother's Cell

Area Code Phone Number

Mother's Facebook

Is the mother of the child Jewish?*

YesNo

Is the father of the child Jewish?*

YesNo

Were there any conversions or adoptions in the family? *

YesNo

If yes, please describe:

Marital Status of Parents:*

MarriedSeparatedDivorced

If divorced - how long?

What goals do you have for your child attending JKC Camp?*

Please share any other information you feel is important for JKC Camp to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.

Comments

Emergency Contact 1*

First Name Last Name

Relation to Child*

Phone Number*

Area Code Phone Number

Business Phone

Area Code Phone Number

Emergency Contact 2*

First Name Last Name

Relation to Child*

Phone Number*

Area Code Phone Number

Business Phone

Area Code Phone Number

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

Doctor's Name*

First Name Last Name

Doctor's Phone*

Area Code Phone Number

Doctor's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Permission for Emergency Medical Treatment:*

As the parent(s) or legal guardian I/we authorize any adult acting on behalf of JKC Camp to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, JKC Camp personnel will try, but are not required, to communicate with me prior to such treatment.I hereby give permission for my child to attend all field trips and outings sponsored by JKC Camp.

Grades K-2 $3400 full summer OR $1750 per month OR $450 per week
Grades 3-6 $3600 full summer OR $1,850 per month OR $500 per week

Register by March 25 to receive $200 off!

My child will be joining JKC CAMP for the full summer

yes

My child will be joining JKC CAMP for the following session

June 28 - July 22July 24 - August 18

My child will be joining JKC CAMP for the following weeks

____________________________________________________________________________________

Extended Hours:
8:30-9:00am
4:00-5:30pm
There are no discounts and no scholarships available for extended hours.

Full Summer

AM & PM $450AM $300PM $300

Month 1

AM & PM $225AM $150PM $150

Month 2

AM & PM $225AM $150PM $150

Week 1

AM & PM $100AM $75PM $75

Week 2

AM & PM $100AM $75PM $75

Week 3

AM & PM $100AM $75PM $75

Week 4

AM & PM $100AM $75PM $75

Week 5

AM & PM $100AM $75PM $75

Week 6

AM & PM $100AM $75PM $75

Week 7

AM & PM $100AM $75PM $75

Week 8

AM & PM $100AM $75PM $75

____________________________________________________________________________________

Commitment*

I understand that by submitting this form I am committing to pay the above outlined camp fees.

Name*

First Name Last Name

Initials*

Date*

Month Day Year

One quarter of your selected program fee is required as a deposit for registration*

Custom price amount, this will be subject to approval from the camp director

$

Additional amount I wish to pay today

$

Payment*

Credit Card Other - I will contact JKC to make my payment

Postal / Zip Code

Country

Total

$0.00

To apply for a scholarship, please click here

JKC CAMP - SUMMER 2023

Camper Information

Father's Information

Mother's Information

Confidential

Other

Emergency File

Registration Information

Secure Online Payment

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