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Children and Youth

Camp

Child's Name*

First Name Last Name
Birth Date*

Month Day Year

Address*

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

Mother's cell*

Area Code Phone Number
father's cell*

Area Code Phone Number
Is your child taking permanent medication?*

yesno
Any known allergies?*

yesno
Confidential: Please list any known allergies
Disclaimer

Accident: As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Chabad of Mesa to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of Mesa personnel will try, but are not required, to communicate with me prior to such treatment.

Trips and Outings: I hereby give permission for my child to attend and participate in all trips and outings organized as part of the program by Chabad of Mesa.

Privacy: I hereby give permission for my child’s photographs/videos to be used in newsletters, local newspapers, Chabad of Mesa website or for promotion of our programs.
Digital signature of parent or legal guardian*

First Name Last Name
date*

Month Day Year
registering for *

week of June 24
total charge-$150 per week*

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

cvv number*
Should be Empty:

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