THE CHABAD CENTER

WINTER EXPERIENCE

ONLINE REGISTRATION

General Information

Father Name*

Last Name*

Mothers Name*

Address *

City*

Postal Code*

Home phone*

Father's Work*

Father Cell*

Mother's Work*

Mother Cell*

parents e-mail address*

Camper Information

Child 1 name*

Date of birth (mm/dd/yy ) *

School & Grade*

Child 2 name

Child 2 date of birth (mm/dd/yy)

Child 2 School & Grade

Dates attending: *
 Tuesday, December 26
Wednesday, December 27

Thursday, December 28

 

Emergency Contact information (other than Parents)

 

Name *

 

Phone *

 

Family Doctor's Name *

Phone Number *

Medical Release/Field Trip Permission
I authorize The Chabad Center and its staff, in case of emergency, to have my child(ren) cared for by a physician in the manner the situation should call for. I permit for my child(ren) to be transported on all trips during the winter camp X

Payment information

I wil pay with a credit card check/cash

Billing Information
Credit Card Type
Card Number
Expiration Date

Security Code



$25 per day

$75 for all days -

Total