Camp "AYOL" Application
Summer 5778
Email address *
Child's Last Name *
English
Your answer
Child's Last Name *
Hebrew Spelling
Your answer
Child's Full First Name *
English
Your answer
Child's Full First Name *
Hebrew Spelling
Your answer
Child's Date of Birth *
English
Your answer
Child's Date of Birth *
Hebrew
Your answer
Home Address *
Street Address, City, State, Zip Code
Your answer
Home Phone
If Applicable
Your answer
Father's Full First & Last Name *
English
Your answer
Father's Full First & Last Name *
Hebrew
Your answer
Father's Cell *
Your answer
Father's Email *
Your answer
Mother's Full First & Last Name *
English
Your answer
Mother's Full First & Last Name *
Hebrew
Your answer
Mother's Cell *
Your answer
Mother's Email *
Your answer
Emergency Contact #1 *
Name, Relationship, Phone
Your answer
Emergency Contact #2 *
Name, Relationship, Phone
Your answer
Your Child's Physician *
Name & Phone
Your answer
Does your child have, or had in the past any health history that we should be aware of? *
Required
Please specify any special needs, allergies, or precautions
Your answer
Weeks that you are registering your child for *
Required
Do you need bus transportation? *
Required
Shirt size ($10 each shirt) *
Required
Camp Fee is $200 a week- all inclusive. All payments should be submitted the beginning of the camp. Please specify your method of payment: *
Required
I hereby confirm that this application form has been read entirely by both parents and signed in full agreement of the above mentioned Terms and Conditions. *
Required
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Father
Your answer
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Mother
Your answer
Date and Time of Submitting the application *
MM
/
DD
/
YYYY
Time
:
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Oholei Yosef Yitzchok Lubavitch,INC.