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Camp Chabad Winter Camp Registration Form
General Information
Child's First Name
*
Child's Last Name
*
Gender
*
M
F
Age
*
Birth Date
*
Grade
*
School Attending
*
Is the child's biological mother Jewish?
*
Yes
No
Please upload conversion documents with registration.
*
Mother's Name
*
Father's Name
*
Home Address
*
City
*
State
*
Zip
*
Email
*
Home Phone
*
Mother's Work Phone
Father's Work Phone
Mother's Cell
*
Father's Cell
*
Emergency Contact
Name
*
Relationship
*
Phone
*
Name
Relationship
Phone
Medical Information
Does your child have allergies, take medication, have a chronic medical condition (asthma, ADHD, seizures, etc.), psychological problems or anything else we may need to know? If yes, explain: (If needed, include more information on a separate piece of paper with the child’s name.)
*
Family Physician
*
Phone
*
Health Insurance (Policy & Number)
*
In case of accident or illness it is agreed that if the parent or emergency contact cannot be reached, Chabad Winter Camp has permission to provide medical care. I also authorize the Chabad staff to administer minor first aid (for cuts, scrapes, etc.) if the need arises. I give my child permission to participate in all camp activities and camp trips. In addition, Chabad Winter Camp can use photographs of my child in its public relations programs.
Parent consent (please enter full name)
*
Attendance
SPECIAL $150 DISCOUNT IF YOU SIGN UP FOR ALL FIVE DAYS!
Days Attending Camp Chabad
*
December 26, ($85)
December 27, ($85)
December 28, ($85)
December 29, ($85)
January 2 , ($85)
I HAVE A COUPON CODE
YES
NO
Coupon code
Special $150 discount for signing up for all five days. Use code "wintercamp"
Comments
Comments
Payment
Payment method
*
Credit Card
PayPal, CashApp, Venmo
Check
Payapl: director@campchabad.org
Venmo: @campchabad
Cashapp: $campchabad
mail a check to:
Camp Chabad
1435 Vine Street
Cincinnati OH 45202
Name on Card
*
Credit Card Number
*
Expiration Date (mm/yy)
*
CVV
*
Billing Zip Code
*
Please consider making a donation to our
camp scholership fund to help a less fortunate child.