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New Student/Camper Intake Form
Please verify reCaptcha before submitting the form.
New Student/Camper Intake Form
PARENT/GUARDIAN 1 INFORMATION
*
Parent/Guardian 1 - First Name
*
Parent/Guardian 1 - Last Name
*
Parent/Guardian 1 - Email Address
*
Parent/Guardian 1 - Mobile Phone
*
Parent/Guardian 1 - Address
*
Parent/Guardian 1 - City
*
Parent/Guardian 1 - State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Parent/Guardian 1 - Zip Code
*
Is there a second parent/guardian?
Please Select One
Yes
No
PARENT/GUARDIAN 2 INFORMATION
*
Parent/Guardian 2 - First Name
*
Parent/Guardian 2 - Last Name
*
Parent/Guardian 2 - Email Address
*
Parent/Guardian 2 - Mobile Phone
*
Does Parent/Guardian 2 live at the same address as Parent/Guardian 1?
Please Select One
Yes
No
Parent/Guardian 2 - Address
Parent/Guardian 2 - City
Parent/Guardian 2 - State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Parent/Guardian 2 - ZIP
STUDENT/CAMPER INFORMATION
*
How many Student/Campers are being registered?
Please Select One
One
Two
Three
STUDENT/CAMPER
1 INFO
*
Student/Camper 1 - First Name
*
Student/Camper 1 - Last Name
*
Student/Camper 1 - Date of Birth
STUDENT/CAMPER
2 INFO
*
Student/Camper 2 - First Name
*
Student/Camper 2 - Last Name
*
Student/Camper 2 - Date of Birth
STUDENT/CAMPER
3 INFO
*
Student/Camper 3 - First Name
*
Student/Camper 3 - Last Name
*
Student/Camper 3 - Date of Birth
Fri, October 4 2024 2 Tishrei 5785