Name of Parent or Guardian *

Name of Parent or Guardian

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Phone

(###)

###

####

Child's Name 1 *

Child's Name 1

First Name

Last Name

Birthday 1 *

Birthday 1

YYYY

Child's Name 2

First Name

Last Name

Birthday 2

YYYY

Child's Name 3

First Name

Last Name

Birthday 3

YYYY

Checkbox *

Choose specific days your child/ren will be attending. ($50 per day-one child; $40 per day-two or more children)

Tuesday, Dec. 26

Wednesday, Dec. 27

Thursday, Dec. 28

Friday, Dec. 29

Name

Emergency Contact

First Name

Last Name

Phone Number

(###)

###

####

Name *

Name

Children's Primary Care Physician

First Name

Last Name

Phone *

Phone

(###)

###

####

List any allergies (if any):

Extended Day

$10 per child- before care; $15 per child- after care until 5:30. List any days you would like to send your children to extended day. Please specify before care or after care.

Method of Payment *

Payment is required for registration. If you do not hear from us within two days of submitting this application, please call 504-456-6429.

Check- mailed to 5210 West Esplanade Ave.

Credit Card- call 504-456-6429

Cash- dropped off at 5210 West Esplanade Ave.

Jewish Camp of the Arts

Torah Academy