Gan Chabad Summer Camp Registration

Name of Student*

First Name Middle Name Last Name

Hebrew Name*

Current Age*

Date of Birth*

Month Day Year

Gender*

Female Male

Home Address*

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

Home Phone*

Area Code Phone Number

Father/Guardian's Information

Father's Name*

Prefix First Name Last Name

Father's Hebrew Name

Father's Occupation*

Father's E-mail*

Father's Cell Phone*

Area Code Phone Number

Father's Work Phone*

Area Code Phone Number

Mother/Guardian's Information

Mother's Name*

Prefix First Name Last Name

Mother's Hebrew Name

Mother's Occupation*

Mother's E-mail*

Mother's Cell Phone*

Area Code Phone Number

Mother's Work Phone

Area Code Phone Number

Family History

Are both the father and mother of child Jewish?*

Yes No

Was any parent or grandparent born not Jewish?*

Yes No

Marital Status*

Married Single Divorced Widowed

Siblings Information

Name

First Name Last Name

Birth Date

Month Day Year

School

Name

First Name Last Name

Birth Date

Month Day Year

School

Class*

Pre- Nursery (18 months- 2.5 yrs old) Nursery (2.5 - 4 yrs old)

Age of Child upon admission date*

Enrollment*

July (July 4-29) August (Aug 2-26) Full Summer

Options*

Mon-Fri 9am-12pm $850/month Mon-Fri 8am-5:30pm $1650/month Mon, Wed, Fri (Pre-N Only) $625/month Tues, Thurs (Pre-N Only) $525/month

Optional Lunch Program 12:00-12:30pm

My child will join the lunch program ($150/month)

Deposit*

Deposit ($350.00) Deposit wil be applied to summer camp fees.

Total

$0.00

Deposit is non-refundable.

The remaining balance will be divided into 2 equal payments charged to your credit card on Apr 1 and May 1.

Please note that photos taken during camp may be used for promotional or publicity purposes.

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Comments

Name of Applicant*

First Name Last Name

Relationship to Child*

How did you hear about us?

Search Engine/ Online Facebook Outdoor Sign Uptown Chabad Programs Friends/ Family

Gan Chabad Summer Camp Registration

Student Information

Family Information

Application Details