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Chabad Jewish Center of Jupiter
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Online Application!

Please fill out the form below carefully.   
When you press submit, this form will be sent to the camp office.    
Camp personel will contact you within one week of receiving your registration.

Note: Please use a separate form for each child.

Camper/Parent Information
Camper
Name
   First  
Middle  
Last  

 Male   
Female 
Address
   Street  
City  
State  
Zip  
Date of Birth
    

Hebrew Birthday

   If unknown; please write time of birth  
Contact Info
   Phone  
Email  
 
School
   School  
Hebrew School  
Entering Grade  

Child is living with:

     Other: 
Camper's Mother
   Mother's Name  
Hebrew Name  Work Phone   
 		 Cell  
    Occupation  
Work Address  
Work Email  
 
Camper's Father
   Father's Name  
Hebrew Name  
Work Phone  
Cell   
    Occupation  
Work Address  
Work Email  
 
Emergency Information
Emergency Contact 1   Name  
Phone  
Relationship   
Emergency Contact 2   Name  
Phone  
Relationship  
 
Pediatrician
   Name  
Phone  
   
Medical Allergies   
Medications & Treatments   
           
Select Child's Grade
 
Entering Kindergarten

  Entering 1-2 Grade

Entering Grade 3-5  
 		 CIT 
   

Please indicate the weeks your child will attend camp  
 (additional weeks can be added throughout the camp season)
 

 Week 1 June 21-25

  Week 2 June 28-July 2  Week 3 July 5-10   
 Week 4 July 12-16    
   
 
 Will need early care (8:00-9:00 am) additional fee of $75 per week will apply
  Will need late care (3:00-5:00 pm) additional fee of $75 per week will apply
 


     
IMPORTANT
•
 All forms must be completed and submitted before your child begins camp.
•
 I will be paying by:  Check-Please make check payable to Chabad of Jupiter and mailed to 128 Glencullen Circle, Jupiter, FL 33458 Please bill me via google checkout. My email address is: 
I have read the camp brochure and application form and agree to the terms stated.  I give my child permission to attend all trips, swim at the Palm Beach Gardens Aquatic Complex and receive medical care in the case of emergency
Must Check for  registrartion acceptance. 

There are no refunds of deposit monies whatsoever.  

Notes
  Date of Application: 
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 Camp Registration Form
Chabad Jewish Center of Jupiter • 128 Glencullen Circle • Jupiter, FL 33458-6534 • 561-694-6950

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