Camper Information

First Name Last Name

Street & apt.

City State/Province Zip

Phone Email

Grade (Next Year):  5 6 7 8 9 10 11 12 Date of Birth:

Called up to Torah as (if 13):  Kohen Levi Yisroel

Returning Camper:   Scouting Background:

My son is applying to be an  overnight day  camper.

Father's Contact Information

Father Name: Father Day:

Father Cell: Father E-mail:

Mother's Contact Information

Mother Name: Mother Day:

Mother Cell: Mother E-mail:

Summer Phone (if different): Marriage Status:

Emergency Contact Information

Contact 1:

Phone: Relationship:

Contact 2:

Phone: Relationship:

Contact 3:

Phone: Relationship:

Education

School Currently Attending:

Previous School: Years:

References

Rebbi Name:

Rebbi Home: Rebbi Work:

Menahel Name:

Menahel Home: Menahel Work:

Health

Health Restrictions:

Medication:

Allergies:

Dietary Restrictions:

Camp T-shirt Orders

T-shirt Size:  Boys S ($10.00) Boys M ($10.00) Boys L ($10.00) Mens S ($10.00) Mens M ($10.00) Mens L ($10.00) Mens XL ($10.00) Mens XXL ($12.00) Mens XXXL ($14.00) T-shirt Quantity: 00 1 2 3 4 5 6 7 8 9 10

Transportation - overnight campers only

To Camp: --None--None Brooklyn Passaic BWI Airport From Camp: --None--None Brooklyn Passaic BWI Airport

Flight Information (if relevant):

Bunk Requests - overnight campers only

Please list three people with whom your son would like to share a tent. (We can not guarantee tent-mates, but we will do our best.)

1)

2)

3)

I understand that acceptance to camp will be decided by Kesher Scouting. Kesher Scouting may use any photos, slides and / or video that include my son. The deposit, which is $500 for overnight campers and $300 for day campers, and all fees are fully-refundable if camper is not accepted to camp. The deposit is otherwise non-refundable. All fees are due in full by May 1, 2012 and are non-refundable thereafter. There are no refunds or partial refunds for early departure or dismissal from camp.