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Printable Registration Form

Printable Registration Form

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Registration Form

 

Lubavitch Day Camp

1171 Waterloo Street
Halifax, Nova Scotia, B3H 3L6

(902)42-CHABAD/422-4222

www.chabadmaritimes.com

 

Name of Camper

______________________________________________________________

Last Name,  First Name, Hebrew

Address

_____________________________________________________________________

Street, City, Province, Postal Code

Date of Birth _________________________

English (MM/DD/YY)

Hebrew School _____________________    Grade Coming Year ______

Father’s Name ___________________ Mother’s Name ______________________

Home Phone Number: ____________________

Father’s Business Phone Number ________________________ Cell ______________________

Profession__________ Business Address: ___________________________________________

Mother’s Business Phone Number _______________________ Cell ______________________

Profession __________ Business Address: ___________________________________________

Emergency Contact ____________________________ Relationship______________________

Emergency Phone Number (Available during all camp hours) _____________________

Swimmer ______ Good____ Fair ____ Poor____ Special Instructions________________

I hereby enroll ____________________________________ as a camper of the Camp Lubavitch Summer Day Camp

Camp 2005. Dates for Summer 2011: 
July 4-July 29 

My child has permission to participate in all Camp Lubavitch supervised activities including

swimming and field trips. If I cannot be contacted in the case of an emergency, Lubavitch Day Camp has the authority to seek medical attention for my child.

Conditions: Registration is accepted only with registration fee of $50 per session. Applications without this fee will be placed on the camp waiting list, with no guaranty of placement. The fee will be applied towards camp tuition. Full camp fees must be paid prior to each session. Refunds depend upon date of applicant’s cancellation. Enclosed Medical Certificate must be signed. Lubavitch Day Camp will make every effort to insure the well-being of every camper. However, it will not be responsible for any injury or health impairment of any camper. Lubavitch Day Camp will not be responsible for damage to or loss of clothing or personal belongings of any camper.

I fully understand the above terms. I have notified Lubavitch Day Camp as to all information requested, as well as any other important facts needed to be known for my child's welfare.

Signature of parent or guardian Date __________________

July 4-29, 2011 (Ages 3-11) -------------------------- $625.00

1/2 Day Program (Ages 2 1/2-3 1/2 ------------------- $525.00
 

Scholarship Requested

(Please turn in separate

Scholarship application)

 

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