Machane Sholom - Congregation Beth Sholom

How Many Children Will Be Registering?

Nonrefundable registration fee is $25 per child.

Child 1 Information

First Name

Last Name

Nickname

Gender

Please Select OneMaleFemale

Birthday

School

Grade Entering

Sessions

Week 1Week 2Week 3Week 4

Does your child take any medication?

Please Select OneYesNo

When does your child need to take medication

During CampNot During Camp

What Type of Medication?

Does Your Child Have Allergies?

Please Select OneYesNo

Epipen?

Please Select OneYesNo

List of Allergies

Child 2 Information

First Name

Last Name

Nickname

Gender

Please Select OneMaleFemale

Birthday

School

Grade Entering

Sessions

Week 1Week 2Week 3Week 4

Does your child take any medication?

Please Select OneYesNo

When does your child need to take medication

During CampNot During Camp

What Type of Medication?

Does Your Child Have Allergies?

Please Select OneYesNo

Epipen?

Please Select OneYesNo

List of Allergies

Child 3 Information

First Name

Last Name

Nickname

Gender

Please Select OneMaleFemale

Birthday

School

Grade Entering

Sessions

Week 1Week 2Week 3Week 4

Does your child take any medication?

Please Select OneYesNo

When does your child need to take medication

During CampNot During Camp

What Type of Medication?

Does Your Child Have Allergies?

Please Select OneYesNo

Epipen?

Please Select OneYesNo

List of Allergies

Child 4 Information

First Name

Last Name

Nickname

Gender

Please Select OneMaleFemale

Birthday

School

Grade Entering

Sessions

Week 1Week 2Week 3Week 4

Does your child take any medication?

Please Select OneYesNo

When does your child need to take medication

During CampNot During Camp

What Type of Medication?

Does Your Child Have Allergies?

Please Select OneYesNo

Epipen?

Please Select OneYesNo

List of Allergies

Parent Information

Father

First Name

Last Name

Father's Email

Father's Cell Phone

Mother

First Name

Last Name

Mother's Email

Mother's Cell Phone

Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

Emergency Information

Emergency Contact

First Name

Last Name

Phone Number

Relationship

Pediatrician

First Name

Last Name

Pediatrician Phone Number

Acknowledgment

I agree to the following Camp Machane Sholom policies:I am signing up my child for Camp Machane Sholom. I give my child permission to attend all trips including swimming and receive medical care in the case of emergency, G-d forbid.

I give Machane Sholom permission to photograph and video my children and use the photos and videos (without their names).

Special payment arrangements must be made before camp starts. If no special arrangement is made, I agree to pay the posted tuition, in full.

Payment

Amount of Children Attending