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Camp Ahavat Hatorah Registration Form
בס״ד
* indicates required fields
Applicant's information
Child Name
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Please select the camp your child will be enrolled in:
*
Pre Toddler Camp
Toddler Camp
Nursery Camp
Kindergarten Camp
Pre 1A Boys Camp
Pre 1A Girls Camp
Home Phone Number
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Father's Information
Father
*
First Name
Last Name
Father's Place of Birth
*
Father's Occupation
*
Father's Business Name
*
Father's Cell
*
Father's Email
*
Language spoken at home
Marital Status
*
Married
Divorced
Separated
Mother's Information
Mother
*
First Name
Last Name
Mother's Place of Birth
*
Mother's Occupation
*
Mother's Business Name
*
Mother's Cell
*
Mother's Email
*
Mother's Maiden name
*
Siblings
Does the applicant have siblings?
*
Yes
No
Number of Siblings
*
Please Select
0
1
2
3
4
5
6
Sibling 1
Name
Sibling 1
Date of Birth
/
Month
/
Day
Year
Sibling 1
School
Sibling 1
Sibling 2
Name
Sibling 2
Date of Birth
/
Month
/
Day
Year
Sibling 2
School
Sibling 2
Sibling 3
Name
Sibling 3
Date of Birth
/
Month
/
Day
Year
Sibling 3
School
Sibling 3
Sibling 4
Name
Sibling 4
Date of Birth
/
Month
/
Day
Year
Sibling 4
School
Sibling 4
Sibling 5
Name
Sibling 5
Date of Birth
/
Month
/
Day
Year
Sibling 5
School
Sibling 5
Sibling 6
Name
Sibling 6
Date of Birth
/
Month
/
Day
Year
Sibling 6
School
Sibling 6
Last Collapse
How Did You Hear About Our Camp Ahavat Hatorah
*
Where do you spend summer?
Which summer camps has your child attended?
*
School presently attending
*
If not applicable, please write NA
Principal's Name
Principal's Phone
Has your child attended more than one school? If yes, please list the schools below:
*
yes
no
Name of school 1
Dates of attendance school 1
Name of school 2
Dates of attendance school 2
Name of school 3
Dates of attendance school 3
Has your child ever been expelled from another school?
*
Yes
No
For disciplinary reasons?
Yes
No
For poor academics?
Yes
No
Other reason
Emergency Contact Information
If Camp Ahavat Hatorah Summer Program cannot reach you, Please list someone we should call, in order of reference.
1.Name
First Name
Last Name
1.Phone Number
*
Please enter a valid phone number.
1.Relationship
2.Name
First Name
Last Name
2.Phone Number
*
Please enter a valid phone number.
2.Relationship
If none of the contacts you have listed can be reached, what should we do if your child is sick or injured?
*
Name of Primary Physician
Phone Number
Please enter a valid phone number.
Does your child have any serious illness?
*
yes
no
Please Specify
How Severe?
Does your child have a physical handicap?
*
yes
no
Please Specify
How Severe?
Does your child have any allergies?
*
yes
no
Please Specify
How Severe?
Consent
*
I hereby certify that the information given in this application is complete and true.
SUBMIT
Should be Empty:
