2004 Camper Application

Camper's Name

Phone Number

Address

City

State

Zip Code

Date of Birth

Sex

Male

Female

Grade Completed as of June 2004

E-Mail Address

Camp Attended Last Year

Years Attended 
"Eddie I"

Member of

Y

JCC

Name of Y or JCC

Membership Expiration Date

Referred By

Synagogue Affiliation

Orthodox Conservative Reform None   

Name Of Synagogue

Parent's E-Mail Address

Father's Name

Employer

Work Phone Number

Type of Business

Mother's Name

Employer

Work Phone Number

Type of Business

Parent's Marital Status

Married Divorced Single Separated Widowed Remarried

If Single Parent, Child Lives With

Not Applicable Mother Father Joint Custody

Other Custodial Parent's Address

To Which Address Should Mailings Be Sent?

Is Either Parent Employed in Jewish Community Service?

Yes

If yes, Where?

Emergency Contact 
(other than parents)

Relationship to Camper

Address

Phone Number

Camp Sessions
(Check One)

Early Bird Rates

2004 - After Jan. 15

Full: 6/27-8/15

$4500

$4700

1st Session: 6/27-7/23

$2550

$2700

2nd Session: 7/25-8/15

$2150

$2300

Two Weeks: 6/27-7/11

$1450

$1550

T.A.C.: Full 6/27-8/15

$5250

$5450

T.A.C.: 1st Session: 6/27-7/23

$2950

$3150

T.A.C.: 2nd Session:  7/25-8/15

$2450

$2600

C.I.T. 6/27-8/15

$2450

$2550

If applicable, deduct:

$100 per additional family member

$100 for any first time Eddie I camper

Less Applicable
Discounts =

Subtotal =

Deposit 
(min $250) =

Balance Due =