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

* Birthday

* School

* Grade Entering

* Sessions

Week 1Week 2Week 3Week 4

* Does your child take any medication?

* When does your child need to take medication

During CampN/ANot During Camp

What Type of Medication?

* Does Your Child Have Allergies?

* Epipen?

List of Allergies

Child 2 Information

* First Name

* Last Name

Nickname

* Gender

Birthday

* School

* Grade Entering

* Sessions

Week 1Week 2Week 3Week 4

* Does your child take any medication?

* When does your child need to take medication

N/ADuring CampNot During Camp

What Type of Medication?

* Does Your Child Have Allergies?

* Epipen?

List of Allergies

Child 3 Information

* First Name

* Last Name

Nickname

* Gender

Birthday

* School

* Grade Entering

* Sessions

Week 1Week 2Week 3Week 4

* Does your child take any medication?

* When does your child need to take medication

N/ADuring CampNot During Camp

What Type of Medication?

* Does Your Child Have Allergies?

* Epipen?

List of Allergies

Child 4 Information

* First Name

* Last Name

Nickname

* Gender

Birthday

* School

* Grade Entering

* Sessions

Week 1Week 2Week 3Week 4

* Does your child take any medication?

* When does your child need to take medication

N/ADuring CampNot During Camp

What Type of Medication?

* Does Your Child Have Allergies?

* Epipen?

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

Total