Printed fromChabadEQ.com

ב"ה

Youth C-TEEN JR.

Register Your Child Online

Online Registration is closed! Please call the office.
* Please Note: This is only the first step to registration. You will need to print out the additional forms and email or fax them in. Your child is not accepted until the camp office confirms receipt of all forms and payment.
Camper Information
Full Name*

First Name Last Name
Hebrew Name*
Gender*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*

Area Code Phone Number
Date of Birth*

Month Day Year
Age*
School Attending*
Entering Grade*
Would you like to sign your child up for soccer camp? (boys 3rd grade and up)

Yes
Parent Information
Father's Full Name*

First Name Last Name
Hebrew Name
Occupation
Phone Number*

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

First Name Last Name
Hebrew Name
Occupation
Phone Number*

Area Code Phone Number
E-mail*
Emergency Contacts

(other than parents)
Contact 1*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Contact 2*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Medical Questionnaire
Any recent surgery or illness?*
Allergies? (Food or medication)*

No Yes
If yes, What kind?
Does your child take medication regularly?*

Yes No
If yes, what kind?
May we give your child Tylenol or Benadryl if needed?*

Yes No
Does your child have any social or emotional problems or any medical conditions of which we should be aware of in caring for him/her?*
Family Doctor*
Address*
Phone Number*

Area Code Phone Number
Payment form

Note: All payment must be paid in FULL by June 9, 2016. NOT included in the pricing is a non-refundable $45 per child registration fee.
Full Summer June 29- August 23

$1700 (payed in full by June 9)
First Session June 29- July 26

$900
Second Session July 27- August 23

$900
Weekly Attendance (Minimum 2 consecutive weeks)

June 29- July 12 July 6 - July 19 July 13- July 26 July 20- August 2 July 27- August 9 August 3 - August 16 August 10- August 23
Non- Refundable Registration Fee*

$45
Weekly Bus Fee Per Family

Week 1 $25 Week 2 $25 Week 3 $25 Week 4 $25 Week 5 $25 Week 6 $25 Week 7 $25 Week 8 $25
There is no reduction or refunds of fees due to absence or illness.

Third Child Discount -$595 Full Summer

Third Child Discount -$315 Per Session

Third Child Discount -$85 Per Week.

(Please call the office for further information regarding the 3rd child discount 718.464.0778)
Total

$0.00

Payment*

Credit Card Check or Cash

Postal / Zip Code

Country

Questions or Comments?
Should be Empty:

This page uses TLS encryption to keep your data secure.