Camp Chabad
Registration Form

PLEASE COMPLETE THE ENTIRE FORM
PLEASE USE ONE FORM PER CAMPER

CAMPER INFORMATION

Childs Last Name:     
First Name:  
Childs Full Hebrew Name:(use english lettering)
Age as of July 1st:  D. O. B.
Jewish Birthday: Date  Month
(Don't Know the Jewish Birthday? Click Here)
Grade Entering:  
Address:  
City:  
Postal Code:  Phone:

PARENT INFORMATION

Mothers Name:
Mothers Full Hebrew Name:
Occupation:  
Email:
Daytime Phone:  Mobile Phone:
Fathers Name:
Fathers Full Hebrew Name:
Occupation:
Daytime Phone:  Mobile Phone:

EMERGENCY CONTACT INFORMATION 

When either parent is not available

Additional Emergency Contact Name:
Full Home Address:
Home Phone:  Work Phone:
Mobile Phone:  
Relationship to Child:
Physician or Medical Facility Name: Phone:

OHIP Number:  

ADDITIONAL CAMPER INFORMATION

Is the child's mother Jewish?  Yes  No 
Is the child's father Jewish?  Yes  No 
Where there any conversions in the family?  Yes   No    If yes, please explain: 
Where there any adoptions in the family?  Yes  No   If yes, please explain: 

School Child is Now Attending:
Hebrew School:
Previous Camp Attended:
Amount of Years:  
Which Activities Does Your Child Enjoy?
In Which Extracurricular Does Your Child Participate Throughout The Year?
Brieflly Describe Your Childs Personality:
Is There Anything Special That We Should Know About Your Child (Allergies, etc.)?
Special Comments:

 

CAMP TUTION

 $105 First week  
$175.00/ Full 5 day week 
I would like to send my child for the week of:

 July 2 
July 7    
July 14 
 $350.00 Full Program-3 weeks

 $300.00 Full Program-3 weeks if registered and paid by February 15 



 $5/day Early drop off. I need early drop off beginning from

 $5/day Late pick up. I will pick my child up by  (latest 5:30) 

 

BILLING INFORMATION


     

Credit Card Number  
Expires (mmyy)

 I will pay by check. Please make all checks payable to Chabad of Mississauga.

 Amount  

Camp Tution is due in Full by July 1, 2014. 
 


Please Do Not Hesitate to call our office at 905-268-4432 if you are in need of financial aid or a Partial Scholarship.

 

PARENTAL CONSENT

I herby 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