Chabad Five Towns Winter Camp Application

Winter Camp 2022 Information:

December 27-29 - 10:00 AM - 4:00 PM

Lunch & Snacks included

Open to children in grades 1-8
Chabad Five Towns Winter Camp Application
Name*

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Number Of Children Registering*

Parent Information
Mother Name *

First NameLast Name
Email*
example@example.com
Cell Phone Number *
Please enter a valid phone number.
Father Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com

Emergency Contact
Name*

First NameLast Name
Email
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Relationship to camper *

Payment Type

Cash / CheckCredit Card
Payment:

Cash / CheckCredit Card

Payment

Tuesday - Urban Air

$60 Number of Children Attending

Wednesday - American Dream Mall

$60 Number of Children Attending

Thursday - Bounce - Trampoline Park

$60 Number of Children Attending

Enter coupon

Total

$0.00

Payment

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Questions: Comments: Concerns:
We are looking forward to having your child join winter camp!

Hadassah Geisinsky will be in touch with you with all camp updates - If you have any questions feel free to reach out to Hadassah - 516-458-3694
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