Child's Last Name
Child's First Name
Child's Full Hebrew Name (type in english)
Age as of July 1st
Child's Date of Birth
Jewish Birthday
(Don't Know the Jewish Birthday? Click Here)
Grade Entering
Postal Code
Mother's Name

Mother's Full Hebrew Name
Daytime Phone
Mobile Phone
Father's Name
Father's Full Hebrew Name
Daytime Phone
Mobile Phone
Emergency Contact Name
(Please do not provide a parent's name. Emergency contact is in case of an emergency and both parents aren't able to be reached.)
Home Phone
Full Home Address
Work Phone
Relationship to Child
Mobile Phone
Physician or Medical Facility Name
OHIP Number
Is the child's mother Jewish? Yes No Is the child's father Jewish? Yes No
Were there any conversions in the family? Yes No     If yes, please explain:
Were there any adoptions in the family? Yes No     If yes, please explain:
School Child is Now Attending
Hebrew School
Previous Camps Attended
Which Activities Does Your Child Enjoy?
In Which Extracurricular Does Your Child Participate Throughout The Year?
Briefly Describe Your Child's Personality:
Is There Anything Special That We Should Know About Your Child (Allergies, etc.)?

$200/Week x =

Week 1 Week 2 Week 3 Week 4
$775 Full Program - 4 weeks
$750 Early Bird Registration by March 2nd
$5/day Early drop off. I need early drop off beginning from (8:00am is earliest) 
$5/day Late pick up. I will pick my child up by (latest 5:30pm)
Payment Type
Credit Card
Cheque (Please make all checks payable to Chabad of Mississauga)
First Name
Total Amount
Last Name
Credit Card Type

Credit Card Number
Expiration Date
CVV Security Code
Postal Code
Camp Tuition is due in Full by July 2, 2020.
Please Do Not Hesitate to call our office at 905-268-4432 if you are in need of financial aid or a partial scholarship. No Jewish child will be turned away due to lack of funds.

I give my child permission to participate in all activities at Chabad's Jewish Day Camp - on-site, off-site and trips. I give permission that any photos taken of my child during camp hours may be used for publicity purpose.

The parent to sign the registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fee.

Sign Name: Date:

Camp Office is 1552 Dundas St. W. Mississauga, ON L5C 1E4
Feel Free to Call 905.268.4432