Online Registration

Camper Information

First Name: Last Name: Gender: MaleFemale

Home Phone: Camper's Email:

Address: City, Province/State: Country:

Date of Birth: 12345678910111213141516171819202122232425262728293031 (Day) JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember (Month) (Year)

Camper Primarily Lives with: Both parents in one homeBoth parents in different homesParent oneParent twoLegal GuardianOther -- If other:

Name of School: Grade Completed: 123456789101112

Current Swimming Level: Adult T-Shirt Size: SmallMediumLargeX-Large

Is English your first language? YesNo -- If no, what is?

Has an Individual Education Plan (IEP) or something similar? YesNo

Gesher group from previous summer: N/AOfarim (2/3)Amelim (4)Chalutzim (5)Solelim (6)Chotrim (7)Bonim (8)MBI (10)

Session from previous summer: N/AFull Session1st Session2nd SessionMadatzOfarim AlephOfarim FullOfarim Bet

Session for this summer: Full Session1st Session2nd SessionMadatzOfarim AlephOfarim FullOfarim Bet

Previous camps and other experience:

Contact Information for Guardian #1

Name: Occupation:

E-mail: Cell Phone:

City, Province/State: Country:

Street Address: Zip/Postal Code:

Contact Information for Guardian #2

Name: Occupation:

E-mail: Cell Phone:

City, Province/State: Country:

Street Address: Zip/Postal Code:

Emergency Contacts (Other than Guardians)

Person 1 Name:

Relation to Camper:

Phone:

Person 2 Name:

Relation to Camper:

Phone:

Miscellaneous

Will the camper require a special diet? NoVegetarianLactose IntolerantPeanut AllergyOther -- If other:

Will the camper be restricted from participating in any activities? YesNo -- If yes, explain:

Is there anything else we should be aware of?