Camper's Name
Phone Number
Address
City
State
Zip Code
Date of Birth
Sex	Male	Female
Grade Completed as of June 2002
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	No
If yes, Where?
Emergency Contact  (other than parents)
Relationship to Camper
Address
Phone Number
Camp Sessions (Check One)	2003 Rates
Full: 6/29 - 8/17	$4250
1st Session: 6/29 - 7/25	$2400
2nd Session: 7/27 - 8/17	$2000
Two Weeks: 6/29 - 7/13	$1300
T.A.C.: Full 6/29 - 8/17	$5000
T.A.C.: 1st Session 6/29 - 7/25	$2850
T.A.C.: 2nd Session  7/27 - 8/17	$2300
C.I.T. 6/29 - 8/17	$2200
	Subtotal =
	Deposit  (min $250) =
	Balance Due =

batterie mugen Blackberry Curve 3G

Submission of this form must be followed by payment by credit card (Mastercard, Visa, Discover)  or check, either by mail or in person, within five working days to ensure camper's spot for Summer 2003.