Camp Ashira | Camper Registration

Camp Ashira | Camper Registration
Camper #1*

First NameLast Name
Birth Date*

MonthDayYear
School Name*
Grade Entering*
Camp Session*
T-Shirt Size*
All T-Shirts are 3/4 Sleeve Shirts. A T-Shirt is $16 and is required for Camp Ashira.

Click Here to Register More Campers
Camper #2

First NameLast Name
Birth Date

MonthDayYear
School Name
Grade Entering
Camp Session
T-Shirt Size
Camper #3

First NameLast Name
Birth Date

MonthDayYear
School Name
Grade Entering
Camp Session
T-Shirt Size
Camper #4

First NameLast Name
Birth Date

MonthDayYear
School Name
Grade Entering
Camp Session
T-Shirt Size
Camper #5

First NameLast Name
Birth Date

MonthDayYear
School Name
Grade Entering
Camp Session
T-Shirt Size

Parent Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mothers Name*

First NameLast Name
Mothers Home Phone*

Area CodePhone Number
Mothers Work Phone*

Area CodePhone Number
Mothers Cell Phone*

Area CodePhone Number
Mothers Email*
Fathers Name

First NameLast Name
Fathers Home Phone

Area CodePhone Number
Fathers Work Phone

Area CodePhone Number
Fathers Cell Phone

Area CodePhone Number
Fathers Email

Emergency Contact Information

This should be a trusted adult that is local, and not the child's parent
Emergency Contact 1*

First NameLast Name
Relationship*
Cell phone*

Area CodePhone Number
Home Phone*

Area CodePhone Number
Emergency Contact 2*

First NameLast Name
Relationship*
Cell phone*

Area CodePhone Number
Home Phone*

Area CodePhone Number
Physician or Medical Facility Name
Phone Number

Area CodePhone Number
Address of Physician or Medical Facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parental Signature
By Signing below I agree to indemnify and hold blameless Congregation Beth Solomon, Camp Ashira and all its employees in case of accident or injury. I hereby give permission for Ashira to administer treatment and/or take my child to the nearest medical facility for treatment at Ashira's discretion.
Signature*

Clear
Please Type Your Full Name*

Registration Payment

To complete your Camp Ashira camper registration please provide your payment information below.

There is a non refundable $50 required Registration Fee.

We can not accept applications without a deposit or payment in full.

Paying Deposit

If you are submitting a deposit with your registration you will be charged according to the following schedule. You will have to enter your credit/debit card information twice to complete the registration. Or provide check information for future payments.

	Full Session	Half Session
Upon Registration	$200	$200
4.30.21	$500	$200
5.30.21	$500	$200
6.10.21	$350	$200

Teen Camp

If you are registering for Teen Camp please provide payment for all the weeks you plan on attending including the $50 registration fee.

Entering 7th Grade: $60 per week

Entering 8th Grade: $50 per week

Please read carefully when choosing your payment options!

Deposit Fee (per Camper)$200.00

The non-refundable deposit for registration ($200) will be taken off the price of camp.

Quantity
Item subtotal:$0.00

Pay In Full - Full 8 Week Session$1,200.00

Quantity
Item subtotal:$0.00

Pay In Full - One Session $550.00

Quantity
Item subtotal:$0.00

T-Shirt$16.00

Quantity
Item subtotal:$0.00

Enter coupon

Total $0.00

Credit Card
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

Future Payments

If you are submitting just a deposit today please provide us with future payment information.
How would you like to pay your future payments.*

Credit/Debit CardCheckPaying In Full Today (No Future Payments Necessary)
To complete your Camp Ashira camper registration please enter your check information below and mail your checks and a copy of this application to:

Camp Ashira

198 Tomlinson Road

Philadelphia PA 19116

There is a $200 non-refundable required Registration Fee per camper. We can not accept applications without a deposit or payment in full.

The non-refundable deposit for registration ($200) will be taken off the total cost for the summer ($1400). Remaining balance after registration is $1200. Remaining balance after early bird registration is $1000.

The non-refundable deposit for registration ($200) will be taken off the cost for one half ($750). Remaining balance after registration is $550. Remaining balance after early bird registration is $450.
Name On Card
Card Number
Exp. Date
Security Code
Confirmation

I agree to have Camp Ashira and CBS Community Center charge my credit/debit card according to the payment schedule above.
Should be Empty:

Camp Ashira | Camper Registration

Parent Information

Emergency Contact Information

Parental Signature

Registration Payment

Future Payments