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Parental Information (click to open section)

* Parent #1 name

* Parent #1 day phone

* Parent #1 cell phone

* Parent #1 email

Parent #2 name

Parent #2 day phone

Parent #2 cell phone

Parent #2 email

* Street Address

* City, State, Zip

Parent Directory

	Yes, you have permission to put our names and phone numbers in the parent directory
	No, you do no thave permission to put our names and phone numbers in the parent directory

Are you a member of Park Synagogue? (check yes or no)

	Yes, I am a member.
	No, I am not a member.

How did you hear about Park Day Camp?

Referred by

Camper #1 Information (click to open)

* Camper's Full Name

* Camper's Birth Date (month/day/year)

* School

* Grade as of Sept. 2024

* Lives with:

If child's address is different from the above parental information please indicate below:

Street Address City, State, Zip

* Does your child attend Jewish Day School?

	Yes, they attend Jewish Day School
	No, they do not attend Jewish Day School

If yes, what school are they attending in the fall?

* Gender

* May we include camper contact information in a camp directory?

* T-shirt Size:

Please include my camper in a group with:

Session selection

2-week session - indicate weeks below
4-week session - indicate weeks below
6-week session - indicate weeks below
8-week session (June 17 - August 9)

Please indicate the consecutive weeks for your session.

Park Synagogue Member Registration Options:

Jewish Day School Registration Options:

Community Options:

Camper #2 Information (click to open)

Camper's Full Name

Camper's Birth Date (month/day/year)

School

Grade as of Sept. 2024

Lives with:

If child's address is different from the above parental information please indicate below:

Street Address City, State, Zip

Does your child attend Jewish Day School?

	Yes, they attend Jewish Day School
	No, they do not attend Jewish Day School

If yes, what school are they attending in the fall?

Gender

May we include camper contact information in a camp directory?

T-shirt Size:

Please include my camper in a group with:

Session selection

2-week session - indicate weeks below
4-week session - indicate weeks below
6-week session - indicate weeks below
8-week session (June 17 - August 9)

Please indicate the consecutive weeks for your session.

Park Synagogue Member Registration Options:

Jewish Day School Registration Options:

Community Options:

Camper #3 Information (click to open)

Camper's Full Name

Camper's Birth Date (month/day/year)

School

Grade as of Sept. 2024

Lives with:

If child's address is different from the above parental information please indicate below:

Street Address City, State, Zip

Does your child attend Jewish Day School?

	Yes, they attend Jewish Day School
	No, they do not attend Jewish Day School

If yes, what school are they attending in the fall?

Gender

May we include camper contact information in a camp directory?

T-shirt Size:

Please include my camper in a group with:

Session selection

2-week session - indicate weeks below
4-week session - indicate weeks below
6-week session - indicate weeks below
8-week session (June 17 - August 9)

Please indicate the consecutive weeks for your session.

Park Synagogue Member Registration Options:

Jewish Day School Registration Options:

Community Options:

Session selection and payment (click to open section)

IMPORTANT NOTES: We reserve the right to withdraw any child, at any time, in the event he/she cannot properly adjust to our camping situation. • In the event that a child is removed at the suggestion of the director there will be a prorated refund. • Camper’s photo may be used for promotional purposes. • A charge of $35.00 will be assessed for any returned checks. • No one shall be denied admission to PDC because of race, creed, color, religion, national origin, gender or disability. • If medical attention is required, it is understood that the first source of payment will be the guardian’s insurance.

* Your initials below indicate that you have read and understand these notes.

* Non-Refundable Deposit (Per Child)

The deposit is applied towards the camp fees and is non-refundable This is $200 per child. All other fees are refundable through June 1.

* If you would like to pay more than just the deposit now, you can enter that amount here $

Donation to Counselor Appreciation Fund

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

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