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Parent 1 Name

Parent 1 Phone Number

Parent 1 Email Address

Parent 2 Name

Parent 2 Phone Number

Parent 1 Email Address

Camper Name

Camper Date of Birth

Month

Day

Year

Address

Grade Level (2025-2026 school year)

Does the Camper have any allergies?

Yes

No

If yes, list allergies:

Does the Camper have any medical conditions? (require an epipen, take medications, etc.)

Yes

No

If yes, please describe:

Does the Camper have any behavioral problems? If so, please describe.

TShirt Size

Is there anything you would like us to know about your child?

Which sessions will your student be attending? $300/week or $2,000 for the full summer.

Title one program - Half day camp $150/week

June 16th - 20th

June 23rd - 27th

Would you like to enroll in after care - 3:30 - 5:00. $60 / week

Yes

No

I give permission for my son/daughter to participate in Nefesh Summer Camp, located at the Jewish Academy at 3100 SW 9th Ave in Fort Lauderdale Florida.

I authorize Nefesh Summer Camp to seek medical treatment for my son/ daughter in the event of an emergency.

I authorize Nefesh Summer Camp to provide meals for my son/ daughter.

Parent Signature

Date

Month

Day

Year

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