Winter Camp Registration 2019 - Brooklyn
Scroll below the image for the registration form

WhatsApp Image 2019-01-28 at 10.08.58 AM.jpeg 

*
Denotes required field


Child Information
First name*
Last name*
Date of birth (mm/dd/yy)*
P.S. number*
Room number
Grade number*
Allergies or medical concerns
Home Address*
City/State/Postal Code*
Home phone number*
Parent's Cell phone*

  Would You Like To Register Multiple Children*   Yes  No

Child #2
First Name
Jewish Hebrew Name
Last Name
 Boy  Girl
Date of Birth (MM/DD/YYYY)
P.S. Number
Grade
Child #3
First Name
Jewish Hebrew Name
Last Name
BoyGirl  
Date of Birth (MM/DD/YYYY)
Grade
 

Payment information
Released Time Winter Camp  Fee    $175
Sign up for Bus Transportation Service Yes No
Method of Payment*
   
Credit card number
Expiration date
Name on Card
CVV (3-4 digit code on card)

Checks can be made out to : Released Time Program, 824 Eastern Parkway, Brooklyn, NY 11213


Email for confirmation*
   

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