Camper Application - Chabad Miami Lakes /NW Dade&STU

Address*

Birthday*

Month Day Year
School*
Grade*
Does the camper have allergies, including asthma?* If yes, please explain.
Is the camper currently under medication?* Please provide the details, the name of medication and period of intake.
Family Information
Father's Full Name*

First Name Last Name
Father's Cell Phone Number*

Area Code Phone Number
Father's E-mail*
Mother's Full Name*

First Name Last Name
Mother's Cell Phone Number*

Area Code Phone Number
Mother's E-mail*
Emergency Contact
1. Full Name*

First Name Last Name
1. Phone Number*

Area Code Phone Number
1. Relation to Camper*
2. Full Name*

First Name Last Name
2. Phone Number*

Area Code Phone Number
2. Relation to Camper*
Registration and Acknowledgements
Registration - $50
Please acknowledge the following:*

I understand my daughter will need to be tested for Covid 19 and provide proof that it is negative or that she is positive for antibodies. I understand if my daughter is accepted the full payment of $2500 will need to be paid within 24 hours or I may forfeit her spot due the amount of applicants. I understand that due to Covid 19 things may change at the last minute. If camp is cancelled you will receive a full refund minus the application fee.
Registration fee now due:

$50.00

Yes, I'd like to donate the cost of processing this transaction by adding 2.9%

Payment*

Credit Card

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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