Registration Form

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Jewish Community Center Religious Youth Orginazation

Machanayim

Camp Application Form

I hereby register my child for the following program(s): (check the appropriate box)

BNOS MACHANAYIM DAY CAMP FOR GIRLS	CAMP MACHANAYIM DAY CAMP FOR BOYS
SLEEPAWAY CAMP FOR GIRLS	MACHANAYIM TINY TOTS
MACHANAYIM FOR "SPECIAL KIDS"	MACHANAYIM "SUNSHINE" PROGRAM

A. PERSONAL

Camper's name: Last First M F

Date of birth: Month day yr Age entering camp: Yrs Mths Entering grade

Years in Israel Place of birth Teudat Zehut/Passport#

Language spoken at home Speaks English: Well Fairly Poorly Not at all

Siblings: Brothers Ages Sisters Ages

Allergies Last tetanus shot

Other specific medical or psychological problems:

Doctor Phone number Health Insurance Plan

B. FAMILY

Family name Father's Mother's

Home address in Israel*

Street, Building/Apartment, Neighborhood, City, Postal Code

Home Phone Fax E-MAIL

Father's Occupation Business phone

Mother's Occupation Business phone

Emergency contact: (Individual to contact in case parents are unavailable)

Relationship Phone Number Address

*Also fill in your address abroad if you permanently reside outside of Israel

Street City State Zip

Phone Number:

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