Registration Form

Name (parent/Guardian)
Address
Apt/ Suite
City
State
Zip
Email
Phone Number

Mothers Name

Daytime Phone (work)

Pager/Cellular

Fathers Name

Daytime Phone (work)

Pager/Cellular

My child will be attending camp.

 
Childs full name
English birthday Hebrew birthday
Hebrew name
Childs Doctor
Doctors Number
Medical Conditions
Medication On
Allergic to foods/medication
Weeks attending
Emergency Info

Emergency Contact

Emergency Contact Phone Number

 

There is a $36 non-refundable deposit per child
(includes childs camp t-shirt)

I would like to pay by Credit Card.

My total is .

 

Please Check Card Type.
Visa Master Card

Card Number

Exp. Date mm/yyyy

Security Code
 

I, the undersigned parent/guardian authorize all camp staff to

1) In case of serious illness/accident to treat camper at the nearest hospital
2) To transport camper in camp bus, van or private vehicle
3) Camper has my permission to participate in all camp activities.

Signature

Additional Comments

For more information or to register more than one child please call us at 217.355.TORA (8672) or email us at [email protected]