Winter Camp Registration 2018 - Brooklyn

* 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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