Campers Name Campers Last Name
Date Of Birth Grade Entering
Guardian or Parent’s Name Address City State ZIP Code Home Phone Email
Cell or Business Phone Emergency Contact
Other people permitted to pick up child(ren)
Pick Up Person 1 Pick Up Person 2 Pick Up Person 3
Child(ren)’s Physician Name Special Concerns / Allergies Kosher Needs Swimmer
Medical Emergency Authorization:
It is our policy to make every effort to reach a parent/guardian in case of emergency. However there are certain times that the camp director needs to act on behalf of the parent. Please authorize the camp director to act on your behalf in the case of a medical emergency.
Authorization
My child (name)
Can watch the following rated movies:
PG
Dates Attending Camp Sibling discount Other discount
Tuition Enclosed Payment Payment
Camp must be paid in full by the first week of camp
