Winter Camp Registration Form

Please fill out the form below carefully. When you press submit, this form will be sent to our administration office.

Application forms must be submitted with registration fee.  Full camp fees must be paid prior to each session.

To download a PDF of the entire form click here. You may register by faxing it to 902-406-7770 or mailing it along with payment to:   Chabad Lubavitch, 1171 Waterloo Street, Halifax, NS B3H 3L6

Note: Please use a separate form for each child.

Camper/Parent Information
Name
   First
Middle Last Hebrew
Address
   Street
City Province 
Postal Code 
Date of Birth
   Hebrew DOB
Contact Info
   Phone
Email
 
Schools
   School
Hebrew School Entering Grade:
Child's Mother
   Mother's Name
Hebrew Name Work Phone Cell
Child's Father
   Father's Name
Hebrew Name Work Phone Cell
Emergency Contact Info
   Name
Phone Relationship  
Pediatrician
   Name
Phone    

Health Card #

      Allergies:  

 Swimmer

  

 Good Fair Poor


 

Special Instructions:

 

  
Select Child's Age Group
Ages 3-11 (Girl) Full Day 9:30 AM-4 PM
Ages 3-11 (Boy) Full Day 9:30 AM-4PM  
 
  
Dates for WINTER 2013/14: Monday, December 30-Friday, January 3
 

  Visa #
Expiry  
Scholarship Requested
(Please turn in separate scholarship application available at the office)

 

 

 Comments:
IMPORTANT
•
 All forms must be completed and submitted before your child begins camp.
 

 Conditions: Registration is accepted only with registration fee of $50. Application fee is non-refundible and will be applied towards camp tuition. Full camp fees must be paid prior to camp session.  Refunds depend upon date of applicant’s cancellation. 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. 

My child has permission to participate in all 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.

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.
  Lubavitch Day Camp was recommended by :
  Date of Application:  Initials: