Camp Leah Rivka

Camper information

First name
*

Last name
*

 

address
*

City
*

State/Province
*

 

Zip/Postal code
*

Phone
*

 

 

Date of birth
*

Hebrew date of birth
*

 

Parents information

Mother's name
*

Maiden name
*

 

 

Cellphone
*

Email
*

 

 

Occupation
*

Business address
*

Business phone
*

 

 

Father's name
*

Cellphone
*

Email
*

 

Occupation

*

Business address
*

Business phone
*

 

Summer information

Do you own a:
*

		Yes	No
TV

*

		Married	Separated	Divorced	Widowed
Marital status

		Mother	Father
Child lives with:

School

School attending
*

Principal
*

Address
*

Phone
*

Hebrew grade completing
*

English grade completing
*

In case of Emergency, and insurance infromation:

Alternative emergency contact:
*

My emergency contact is a
*

• 
  Freind
• 
  Relative
• 
  Other:
  

Health Insurance Provider

*

Phone
*

Health Isurance number
*

Childs Physician

Phone

Does Your child have any:
*

		Yes	No
Medical Conditions
Allergies

If yes please describe