Teen Information
First Name (shown on ID)*
 Current Grade*

Weeks Attending*

Parent Information
Marital Status*
How did you hear about us*
Father's Name

Mother's Name

NOTE: We accept conversions recognized by the rabbinical courts in Israel (Rabanut of Israel).
Health & Transportation
Medical Insurance
Insurance Provider* Name of Policy Holder* Member ID #*
Emergency Contact Information
Physician or Medical Facility*
Parental Consent and Transportation Information
I hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately. Initialize*
I hereby give permission for my child to be transported and participate in field trips during operating hours. Details will be sent to me in advance Initialize*
Health History and Special Instructions
List any illnesses your child had within past 6 months
List any Sensitivities your child has. Any dislikes you feel we should be aware of?
Does your child have any allergies?
If yes, please list allergies
Does your child have a history of
Physical handicaps Rheumatic fever Heart problems Seizures Asthma Diabetes Other (describe)
Please describe any instructions that would be helpful in caring or for your child, or special medical information needed by the child’s care staff/provider.
Registration Fee & Payment Options

authorize a $100 non refundable deposit to be charged immediately and credited toward tuition (will be refunded if the application is not accepted).

I understand that all applicants will be contacted to schedule a meeting with Rabbi Elishevitz to discuss: expected behavior, sign a behavior contract and bring along a check in the amount of $250 as a refundable security deposit. (the check will be returned on the last day of camp).

Camp Fee & Deadlines:
Early bird $475 per week until March 1st; Regular price $500 after
Registration closes May 1st
After May 1st, Late registration price $550 will be on wait list
Camp Odyssey: $1,800

*Payment Options

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* Comments