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<p> </p>
<p style="font-family: Arial; font-size: 14px; line-height: 25.2px; background: white;">
<span style="font-size: 10pt; font-family: Tahoma, sans-serif; color: rgb(38, 62, 174);">$75 non-refundable registration fee per camper due with registration. The registration fee will be applied toward the total camp tuition.</span><span class=" apple-converted-space" style="font-size: 9pt; font-family: Tahoma, sans-serif; color: rgb(38, 62, 174);"> <strong>Please note: On the online registration, just the deposit is charged. The office will generate an invoice shortly, and send it to you. At that point, you can either complete payment by credit card or check.</strong></span></p>
<p style="font-family: Arial; font-size: 14px; line-height: 25.2px; background: white;">
<strong>
<span style="font-size: 9pt; font-family: Tahoma, sans-serif; color: rgb(38, 62, 174);">
<a href="https://myjewishcamporg.clhosting.org/Article.asp?AID=1430433" style="color: rgb(0, 79, 157);">
<span style="color: rgb(38, 62, 174);">Click here</span></a></span></strong><span class="apple-converted-space"> <b>
</b></span><strong>
<span style="font-size: 9pt; font-family: Tahoma, sans-serif; color: rgb(38, 62, 174);">for dates and rates.</span></strong></p>
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<strong>
<span style="font-size: 9pt; font-family: Arial, sans-serif; color: red;">We are excited to offer the  great deal below  for the</span><u>
<em>
<span style="font-size: 9pt; font-family: Arial, sans-serif; color: red;"> 4<sup>th</sup> year!</span></em></u></strong></p>
<p style="font-family: Arial; font-size: 14px; line-height: 25.2px; background: white;">
<strong>
<span style="font-size: 9pt; font-family: Arial, sans-serif; color: red;">FIRST WEEK SPECIAL!</span></strong><span class=" apple-converted-space" style="font-size: 9pt; font-family: Tahoma, sans-serif; color: rgb(38, 62, 174);"> </span><strong> <span style="font-size: 9pt; font-family: Arial, sans-serif; color: rgb(38, 62, 174);">JUST $25 FOR THE FIRST WEEK! Use promo code '25CAMPER'.* Limited availability, first come first serve basis.  Call 344.4900 or email <a href="mailto:Director@MyJewishCamp.org" style="color: rgb(0, 79, 157);">
<span style="font-weight: normal;">Director@MyJewishCamp.org</span></a>.</span></strong></p>
<p style="font-family: Arial; font-size: 14px; line-height: 25.2px; background: white;">
<strong>
<span style="font-size: 9pt; font-family: Arial, sans-serif; color: rgb(38, 62, 174);">Thanks to Drs. Allan and Lora Alexander for generously underwriting this grant.</span></strong></p>
<p style="font-family: Arial; font-size: 14px; line-height: 25.2px; background: white;">
<strong>
<span style="font-size: 12px; color: rgb(0, 0, 128);"> </span></strong><span style="font-size: 9pt; font-family: Tahoma, sans-serif; color: rgb(38, 62, 174);">We will send out an acceptance letter and invoice shortly after we receive your registration.</span></p>
<p style="font-family: Arial; font-size: 14px; line-height: 25.2px; background: white;">
<strong>Camp T-shirts are available for purchase ($7 each) on the form below if desired. Tshirt orders must be received by June 1st.</strong></p>
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<strong>Address</strong></div>
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<font class="Tiny_text">Street <br>
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<strong>Contact Info</strong></div>
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<font class="Tiny_text">Mother's Email <br>
</font><input tabindex="0" id="Email" class="Form_Text_box" size="16" autocomplete="OFF" required="true" name="mothers email" type="text"></td>
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<td width="136"> </td>
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<strong>Mother</strong></div>
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<font class="Tiny_text">Mother's Name <br>
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<font class="Tiny_text">Hebrew Name</font><input tabindex="0" id="Mother_Hebrew_Name" class="Form_Text_box" size="15" required="true" name="Mother_Hebrew_Name" type="text"></td>
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<font class="Tiny_text">Cell <br>
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<div class="regular_text" align="right"> </div>
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<strong>Father</strong></div>
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<font class="Tiny_text">Father's Name <br>
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</font><input tabindex="0" id="Father_Cell_Phone" class="Form_Text_box" size="10" autocomplete="OFF" required="true" name="Father_Cell_Phone" type="text"></td>
</tr>
<tr bgcolor="#BEDAFF" style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<strong>Emergency Contact Info</strong></div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">Name <br>
</font><input tabindex="0" id="Emergency_Name" class="Form_Text_box" size="12" autocomplete="OFF" required="true" name="Emergency_Name1" type="text"></td>
<td width="194">
<font class="Tiny_text">Phone <br>
</font><input tabindex="0" id="Emergency_Phone" class="Form_Text_box" size="15" autocomplete="OFF" required="true" name="Emergency_Phone1" type="text"></td>
<td width="133">
<font class="Tiny_text">Relationship <br>
</font><input tabindex="0" id="Emergency_Relationship" class="Form_Text_box" size="15" required="true" name="Emergency_Relationship1" type="text"></td>
<td width="136"> </td>
</tr>
<tr>
<td colspan="2">
<div class="regular_text" align="right"> </div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">Name <br>
</font><input tabindex="0" id="Emergency_Name" class="Form_Text_box" size="12" autocomplete="OFF" required="true" name="Emergency_Name2" type="text"></td>
<td width="194">
<font class="Tiny_text">Phone <br>
</font><input tabindex="0" id="Emergency_Phone" class="Form_Text_box" size="15" autocomplete="OFF" required="true" name="Emergency_Phone2" type="text"></td>
<td width="133">
<font class="Tiny_text">Relationship <br>
</font><input tabindex="0" id="Emergency_Relationship" class="Form_Text_box" size="15" required="true" name="Emergency_Relationship2" type="text"></td>
<td width="136"> </td>
</tr>
<tr bgcolor="#BEDAFF" style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<strong>Pediatrician</strong></div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">Name <br>
</font><input tabindex="0" id="Doctor_Name" class="Form_Text_box" size="12" autocomplete="OFF" required="true" name="Pediatrician" type="text"></td>
<td width="194">
<font class="Tiny_text">Phone <br>
</font><input tabindex="0" id="Doctor_Phone" class="Form_Text_box" size="15" autocomplete="OFF" required="true" name="Doctor_Phone" type="text"></td>
<td width="133">
<p>Who can we thank for referring you? <input type="text" name="Who can we thank for referring you?" tabindex="1" required="false"></p>
</td>
<td width="136"> </td>
</tr>
<tr>
<td colspan="2"> </td>
<td width="1"> </td>
<td colspan="2"> </td>
<td width="194"> </td>
<td width="133"> </td>
<td width="136"> </td>
</tr>
<tr bgcolor="#660099" style="font-family:">
<td bgcolor="#660099" colspan="5">
<div class="regular_text" align="left">
<strong>
<span style="color: #ffffff">Camper 1 Information</span></strong></div>
</td>
<td bgcolor="#660099" width="194"> </td>
<td bgcolor="#660099" width="133"> </td>
<td bgcolor="#660099" width="136"> </td>
</tr>
<tr bgcolor="#ffffff" style="font-family:">
<td bgcolor="#ffffff" colspan="2">
<div class="regular_text" align="right">
<strong>Name</strong></div>
</td>
<td bgcolor="#ffffff" width="1"> </td>
<td bgcolor="#ffffff" colspan="2">
<font class="Tiny_text">First Name <br>
</font><input tabindex="0" id="Emergency_Name" class="Form_Text_box" size="12" required="true" name="Camper_Name1" type="text"></td>
<td bgcolor="#ffffff" width="194">
<font class="Tiny_text">Middle Name <br>
</font><input tabindex="0" id="Emergency_Name" class="Form_Text_box" size="12" required="true" name="Middle_Name1" type="text"></td>
<td bgcolor="#ffffff" width="133">
              <font color="#000080">
<font size="1">Gender</font>
              </font>
<br>
<select tabindex="0" name="gender1">
<option value="M" selected>M</option>
<option value="F">F</option>
</select></td>
<td bgcolor="#ffffff" width="136"> </td>
</tr>
<tr>
<td bgcolor="#BEDAFF" colspan="2">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Date of Birth</strong></strong></div>
</div>
</td>
<td bgcolor="#BEDAFF" width="1"> </td>
<td bgcolor="#BEDAFF" colspan="2">
<select tabindex="0" id="Date_Of_Birth_Month" class="regular_text" name="Date_Of_Birth_Month">
<option value="Select Month" selected>Select Month</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select></td>
<td bgcolor="#BEDAFF" width="194">
<select tabindex="0" id="Date_Of_Birth_Day" class="regular_text" name="Date_Of_Birth_Day1">
<option value="Select Date" selected>Select Date</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></td>
<td bgcolor="#BEDAFF" width="133">
<select tabindex="0" id="Date_Of_Birth_Year" class="regular_text" name="Date_Of_Birth_Year1">
<option value="Select Year" selected>Select Year</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
</select></td>
<td bgcolor="#BEDAFF" width="136"> </td>
</tr>
<tr style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<strong>Schools</strong></div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">School <br>
</font><input tabindex="0" id="School" class="Form_Text_box" size="15" required="true" name="School1" type="text"></td>
<td colspan="2">
<font class="Tiny_text">
<strong class="tiny_text" style="font-weight: 400">Entering Grade:  <br>
</strong><input tabindex="0" id="Entering_Grade" class="Form_Text_box" size="10" required="true" name="Entering_Grade1" type="text"></font>
            </td>
<td class="regular_text" width="136" colspan="2"> </td>
</tr>
<tr bgcolor="#C6D7FF" style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Quick Health Notes</strong></strong></div>
</div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">Medication  <br>
</font><input tabindex="0" class="Form_Text_box" size="12" required="true" name="medication1" type="text"></td>
<td width="194">
<font class="Tiny_text">Allergies <br>
<input tabindex="0" class="Form_Text_box" size="12" required="true" name="allergies1" type="text"></font>
            </td>
<td width="133"> </td>
<td width="136"> </td>
</tr>
<tr style="font-family:">
<td colspan="2">
<div class="regular_text" align="right"> </div>
</td>
<td width="1"> </td>
<td colspan="5">
<font class="Tiny_text">Health Issues, disabilities or special needs of child: <br>
<input tabindex="0" class="Form_Text_box" size="61" required="true" style="height: 17px; width: 412px" name="health_problems_or_disabilities1" type="text"></font>
            </td>
</tr>
<tr bgcolor="#ffffff" style="font-family:">
<td bgcolor="#C6D7FF" colspan="2">
<p align="right">
<strong>
<strong>T-shirt size</strong></strong></p>
</td>
<td bgcolor="#C6D7FF" width="1"> </td>
<td bgcolor="#C6D7FF" colspan="5">
<select tabindex="0" class="regular_text" name="tshirt size1">
<option value="Select" selected>Select</option>
<option value="S (6-8)">S (6-8)</option>
<option value="M (10-12)">M (10-12)</option>
<option value="L (12-14)">L (12-14)</option>
<option value="XL (14-16)">XL (14-16)</option>
<option value="(A) S">(A) S</option>
<option value="(A) M">(A) M</option>
<option value="(A) L">(A) L</option>
<option value="(A) XL">(A) XL</option>
<option value="(A) 2X">(A) 2X</option>
<option value="(A) S">(A) S</option>
</select><font color="#000080">(A) implies adult sizes</font>
            </td>
</tr>
<tr bgcolor="#C6D7FF" style="font-family:">
<td bgcolor="#ffffff" colspan="2">
<div class="regular_text" align="right">
<p align="right">
<strong>
<strong>
<strong>Age group</strong></strong></strong></p>
</div>
</td>
<td bgcolor="#ffffff" width="1"> </td>
<td bgcolor="#ffffff" colspan="2">
<input tabindex="0" type="radio" name="Agegroup1" value="Explorers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Explorers: Grades K - 1</span></td>
<td bgcolor="#ffffff" width="194">
<div align="left">
<input tabindex="0" type="radio" name="Agegroup1" value="Trailblazers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Trailblazers: Grades 2 - 4 </span></div>
</td>
<td bgcolor="#ffffff" colspan="2">
<input tabindex="0" type="radio" name="Agegroup1" value="Pioneers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Pioneers: Grades 5 – 7 </span></td>
</tr>
<tr bgcolor="#ffffff" valign="top" style="font-family:">
<td class="regular_text" bgcolor="#C6D7FF" colspan="2">
<p align="right">
<strong>
<strong>Sessions attending &amp; Additional requirements</strong></strong></p>
</td>
<td class="tiny_text" bgcolor="#C6D7FF" width="1"> </td>
<td class="tiny_text" bgcolor="#C6D7FF" colspan="2"><input tabindex="0" type="checkbox" name="Full Session1" value="on">Full Session <br>
<input tabindex="0" type="checkbox" name="Week1-1" value="on">Week 1  <br>
<input tabindex="0" type="checkbox" name="Week 2-1" value="on">Week 2 <br>
<input tabindex="0" type="checkbox" name="Week 3-1" value="on">Week 3<br>
<input type="checkbox" name="Week 4 -1" tabindex="0">Week 4</td>
<td bgcolor="#C6D7FF" width="194">
<p><input tabindex="0" type="checkbox" name="Before Care1" value="on"><span style="font-size: 10px">Yes, I will need Before Care 8:00-9:00 am <br>
</span><br>
<span style="font-size: 10px"><input tabindex="0" type="checkbox" name="After Care1" value="on">Yes, I will need After Care 3:30-5:00</span>
<span style="font-size: 10px">pm</span></p>
</td>
<td bgcolor="#C6D7FF" colspan="2"> </td>
</tr>
<tr bgcolor="#67009B" style="font-family:">
<td bgcolor="#ffffff" colspan="5"> </td>
<td bgcolor="#ffffff"> </td>
<td bgcolor="#ffffff"> </td>
<td bgcolor="#ffffff"> </td>
</tr>
<tr bgcolor="#67009B" style="font-family:">
<td bgcolor="#660099" colspan="5">
<div class="regular_text" align="left">
<strong>
<span style="color: #ffffff">Camper 2 Information</span></strong></div>
</td>
<td bgcolor="#660099" width="194"> </td>
<td bgcolor="#660099" width="133"> </td>
<td bgcolor="#660099" width="136"> </td>
</tr>
<tr bgcolor="#ffffff" style="font-family:">
<td bgcolor="#ffffff" colspan="2">
<div class="regular_text" align="right">
<strong>Name</strong></div>
</td>
<td bgcolor="#ffffff" width="1"> </td>
<td bgcolor="#ffffff" colspan="2">
<font class="Tiny_text">First Name <br>
</font><input tabindex="0" class="Form_Text_box" size="12" name="first_Name2" type="text"></td>
<td bgcolor="#ffffff" width="194">
<font class="Tiny_text">Middle Name <br>
</font><input tabindex="0" class="Form_Text_box" size="12" name="middle_Name2" type="text"></td>
<td bgcolor="#ffffff" width="133">
<font color="#000080" size="1">Gender <br>
</font><select tabindex="0" name="gender2">
<option value="M" selected>M</option>
<option value="F">F</option>
</select></td>
<td bgcolor="#ffffff" width="136"> </td>
</tr>
<tr>
<td bgcolor="#BEDAFF" colspan="2">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Date of Birth</strong></strong></div>
</div>
</td>
<td bgcolor="#BEDAFF" width="1"> </td>
<td bgcolor="#BEDAFF" colspan="2">
<select tabindex="0" id="Date_Of_Birth_Month" class="regular_text" name="Date_Of_Birth_Month2">
<option value="Select Month" selected>Select Month</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select></td>
<td bgcolor="#BEDAFF" width="194">
<select tabindex="0" id="Date_Of_Birth_Day" class="regular_text" name="Date_Of_Birth_Day2">
<option value="Select Date" selected>Select Date</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></td>
<td bgcolor="#BEDAFF" width="133">
<select tabindex="0" id="Date_Of_Birth_Year" class="regular_text" name="Date_Of_Birth_Year2">
<option value="Select Year" selected>Select Year</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
</select></td>
<td bgcolor="#BEDAFF" width="136"> </td>
</tr>
<tr style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<strong>Schools</strong></div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">School <br>
</font><input tabindex="0" id="School" class="Form_Text_box" size="15" name="School2" type="text"></td>
<td colspan="2">
<font class="Tiny_text">
<strong class="tiny_text" style="font-weight: 400">Entering Grade: <br>
</strong><input tabindex="0" id="Entering_Grade" class="Form_Text_box" size="10" name="Entering_Grade2" type="text"></font>
            </td>
<td class="regular_text" width="136" colspan="2"> </td>
</tr>
<tr bgcolor="#C6D7FF" style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Quick Health Notes</strong></strong></div>
</div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">Medication  <br>
</font><input tabindex="0" id="Doctor_Name" class="Form_Text_box" size="12" name="medication2" type="text"></td>
<td width="194">
<font class="Tiny_text">Allergies <br>
<input tabindex="0" id="Doctor_Name" class="Form_Text_box" size="12" name="allergies2" type="text"></font>
            </td>
<td width="133"> </td>
<td width="136"> </td>
</tr>
<tr style="font-family:">
<td colspan="2">
<div class="regular_text" align="right"> </div>
</td>
<td width="1"> </td>
<td colspan="5">
<font class="Tiny_text">Health Issues, disablities or special needs of child: <br>
<input tabindex="0" id="Doctor_Name" class="Form_Text_box" size="61" style="height: 17px; width: 412px" name="health_problems_or_disabilities2" type="text"></font>
            </td>
</tr>
<tr bgcolor="#ffffff" style="font-family:">
<td bgcolor="#C6D7FF" colspan="2">
<p align="right">
<strong>
<strong>T-shirt size</strong></strong></p>
</td>
<td bgcolor="#C6D7FF" width="1"> </td>
<td bgcolor="#C6D7FF" colspan="5">
<select tabindex="0" class="regular_text" name="tshirt size2">
<option value="Select" selected>Select</option>
<option value="S (6-8)">S (6-8)</option>
<option value="M (10-12)">M (10-12)</option>
<option value="L (12-14)">L (12-14)</option>
<option value="XL (14-16)">XL (14-16)</option>
<option value="(A) S">(A) S</option>
<option value="(A) M">(A) M</option>
<option value="(A) L">(A) L</option>
<option value="(A) XL">(A) XL</option>
<option value="(A) 2X">(A) 2X</option>
</select><font class="tiny_text">(A) implies adult sizes</font>
            </td>
</tr>
<tr bgcolor="#C6D7FF" style="font-family:">
<td bgcolor="#ffffff" colspan="2">
<div class="regular_text" align="right">
<p align="right">
<strong>
<strong>
<strong>Age group</strong></strong></strong></p>
</div>
</td>
<td bgcolor="#ffffff" width="1"> </td>
<td bgcolor="#ffffff" colspan="2">
<input tabindex="0" type="radio" name="Agegroup2" value="Explorers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Explorers: Grades K - 1</span></td>
<td bgcolor="#ffffff" width="194">
<div align="left">
<input tabindex="0" type="radio" name="Agegroup2" value="Trailblazers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Trailblazers: Grades 2 - 4 </span></div>
</td>
<td bgcolor="#ffffff" colspan="2">
<input tabindex="0" type="radio" name="Agegroup2" value="Pioneers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Pioneers: Grades 5 – 7 </span></td>
</tr>
<tr valign="top" style="font-family:">
<td class="regular_text" bgcolor="#C6D7FF" colspan="2">
<p align="right">
<strong>
<strong>Sessions attending &amp; Additional requirements</strong></strong></p>
</td>
<td class="tiny_text" bgcolor="#C6D7FF" width="1"> </td>
<td class="tiny_text" bgcolor="#C6D7FF" colspan="2"><input tabindex="0" type="checkbox" name="Full Session2" value="on">Full Session <br>
<input tabindex="0" type="checkbox" name="Week1-2" value="on">Week 1  <br>
<input tabindex="0" type="checkbox" name="Week 2-2" value="on">Week 2 <br>
<input tabindex="0" type="checkbox" name="Week 3-2" value="on">Week 3<br>
<input type="checkbox" name="Week 4-2" tabindex="0">Week 4</td>
<td bgcolor="#C6D7FF" width="194">
<p>
<input tabindex="0" type="checkbox" name="Before Care 2" value="on"><span style="font-size: 10px">Yes, I will need Before Care 8:00-9:00 am</span><span style="font-size: 10px"><br>
</span><span style="font-size: 10px"><br>
<input tabindex="0" type="checkbox" name="After Care2" value="on">Yes, I will need After Care 3:30-5:00 pm</span></p>
</td>
<td bgcolor="#C6D7FF" colspan="2"> </td>
</tr>
<tr style="font-family:">
<td bgcolor="#ffffff" colspan="5"> </td>
<td bgcolor="#ffffff"> </td>
<td bgcolor="#ffffff"> </td>
<td bgcolor="#ffffff"> </td>
</tr>
<tr style="font-family:">
<td bgcolor="#660099" colspan="5">
<div class="regular_text" align="left">
<strong>
<span style="color: #ffffff">Camper 3 Information</span></strong></div>
</td>
<td bgcolor="#660099" width="194"> </td>
<td bgcolor="#660099" width="133"> </td>
<td bgcolor="#660099" width="136"> </td>
</tr>
<tr bgcolor="#ffffff" style="font-family:">
<td bgcolor="#ffffff" colspan="2">
<div class="regular_text" align="right">
<strong>Name</strong></div>
</td>
<td bgcolor="#ffffff" width="1"> </td>
<td bgcolor="#ffffff" colspan="2">
<font class="Tiny_text">First Name <br>
</font><input tabindex="0" class="Form_Text_box" size="12" name="First_Name3" type="text"></td>
<td bgcolor="#ffffff" width="194">
<font class="Tiny_text">Middle Name <br>
</font><input tabindex="0" class="Form_Text_box" size="12" name="middle_Name3" type="text"></td>
<td bgcolor="#ffffff" width="133">
<font color="#000080" size="1">Gender <br>
</font><select tabindex="0" name="gender3">
<option value="M" selected>M</option>
<option value="F">F</option>
</select></td>
<td bgcolor="#ffffff" width="136"> </td>
</tr>
<tr>
<td bgcolor="#BEDAFF" colspan="2">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Date of Birth</strong></strong></div>
</div>
</td>
<td bgcolor="#BEDAFF" width="1"> </td>
<td bgcolor="#BEDAFF" colspan="2">
<select tabindex="0" id="Date_Of_Birth_Month" class="regular_text" name="Date_Of_Birth_Month3">
<option value="Select Month" selected>Select Month</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select></td>
<td bgcolor="#BEDAFF" width="194">
<select tabindex="0" id="Date_Of_Birth_Day" class="regular_text" name="Date_Of_Birth_Day3">
<option value="Select Date" selected>Select Date</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></td>
<td bgcolor="#BEDAFF" width="133">
<select tabindex="0" id="Date_Of_Birth_Year" class="regular_text" name="Date_Of_Birth_Year3">
<option value="Select Year" selected>Select Year</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
</select></td>
<td bgcolor="#BEDAFF" width="136"> </td>
</tr>
<tr style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<strong>Schools</strong></div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">School <br>
</font><input tabindex="0" id="School" class="Form_Text_box" size="15" name="School3" type="text"></td>
<td colspan="2">
<font class="Tiny_text">
<strong class="tiny_text" style="font-weight: 400">Entering Grade: <br>
</strong><input tabindex="0" id="Entering_Grade" class="Form_Text_box" size="10" name="Entering_Grade3" type="text"></font>
            </td>
<td class="regular_text" width="136" colspan="2"> </td>
</tr>
<tr bgcolor="#C6D7FF" style="font-family:">
<td colspan="2">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Quick Health Notes</strong></strong></div>
</div>
</td>
<td width="1"> </td>
<td colspan="2">
<font class="Tiny_text">Medication  <br>
</font><input tabindex="0" class="Form_Text_box" size="12" name="medication3" type="text"></td>
<td width="194">
<font class="Tiny_text">Allergies <br>
<input tabindex="0" class="Form_Text_box" size="12" name="allergies3" type="text"></font>
            </td>
<td width="133"> </td>
<td width="136"> </td>
</tr>
<tr style="font-family:">
<td colspan="2">
<div class="regular_text" align="right"> </div>
</td>
<td width="1"> </td>
<td colspan="5">
<font class="Tiny_text">Health Issues, disabilities or special needs of child: <br>
<input tabindex="0" id="Doctor_Name" class="Form_Text_box" size="61" style="height: 17px; width: 412px" name="health_problems_or_disabilities3" type="text"></font>
            </td>
</tr>
<tr bgcolor="#ffffff" style="font-family:">
<td bgcolor="#C6D7FF" colspan="2">
<p align="right">
<strong>
<strong>T-shirt size</strong></strong></p>
</td>
<td bgcolor="#C6D7FF" width="1"> </td>
<td bgcolor="#C6D7FF" colspan="5">
<select tabindex="0" class="regular_text" name="tshirt size3">
<option value="Select" selected>Select</option>
<option value="S (6-8)">S (6-8)</option>
<option value="M (10-12)">M (10-12)</option>
<option value="L (12-14)">L (12-14)</option>
<option value="XL (14-16)">XL (14-16)</option>
<option value="(A) S">(A) S</option>
<option value="(A) M">(A) M</option>
<option value="(A) L">(A) L</option>
<option value="(A) XL">(A) XL</option>
<option value="(A) 2X">(A) 2X</option>
</select><font color="#000080">(A) implies adult sizes</font>
            </td>
</tr>
<tr bgcolor="#C6D7FF" style="font-family:">
<td bgcolor="#ffffff" colspan="2">
<div class="regular_text" align="right">
<p align="right">
<strong>
<strong>
<strong>Age group</strong></strong></strong></p>
</div>
</td>
<td bgcolor="#ffffff" width="1"> </td>
<td bgcolor="#ffffff" colspan="2">
<input tabindex="0" type="radio" name="Agegroup3" value="Explorers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Explorers: Grades K - 1</span></td>
<td bgcolor="#ffffff" width="194">
<div align="left">
<input tabindex="0" type="radio" name="Agegroup3" value="Trailblazers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Trailblazers: Grades 2 - 4 </span></div>
</td>
<td bgcolor="#ffffff" colspan="2">
<input tabindex="0" type="radio" name="Agegroup3" value="Pioneers"><span style="font-size: 7pt; font-family: Tahoma; color: #000080">Pioneers: Grades 5 – 7 </span></td>
</tr>
<tr valign="top" style="font-family:">
<td class="regular_text" bgcolor="#C6D7FF" colspan="2">
<p align="right">
<strong>
<strong>Sessions attending &amp; Additional requirements</strong></strong></p>
</td>
<td class="tiny_text" bgcolor="#C6D7FF" width="1"> </td>
<td class="tiny_text" bgcolor="#C6D7FF" colspan="2"><input tabindex="0" type="checkbox" name="Full Session3" value="on">Full Session <br>
<input tabindex="0" type="checkbox" name="Week1-3" value="on">Week 1  <br>
<input tabindex="0" type="checkbox" name="Week 2-3" value="on">Week 2 <br>
<input tabindex="0" type="checkbox" name="Week 3-3" value="on">Week 3<br>
<input type="checkbox" name="Week 4-3" tabindex="0">Week 4</td>
<td bgcolor="#C6D7FF" width="194">
<p>
<input tabindex="0" type="checkbox" name="Before Care 3" value="on"><span style="font-size: 10px">Yes, I will need Before Care 8:00-9:00 am</span><span style="font-size: 10px"><br>
</span><span style="font-size: 10px"><br>
<input tabindex="0" type="checkbox" name="After Care 3" value="on">Yes, I will need After Care 3:30-5:00 pm</span></p>
</td>
<td class="tiny_text" bgcolor="#C6D7FF" colspan="2"> </td>
</tr>
<tr>
<td width="90"> </td>
<td colspan="2"> </td>
<td colspan="5"> </td>
</tr>
<tr>
<td class="White_Text" bgcolor="#990000" colspan="8">
<strong>
<span style="font-size: 9pt; color: #ffffff">IMPORTANT</span></strong></td>
</tr>
<tr>
<td bgcolor="#ffffff" width="90">
<div align="right">
<div align="right">
<span class="regular_text" style="font-size: 7pt">•</span></div>
</div>
</td>
<td class="regular_text" bgcolor="#ffffff" colspan="7">All forms must be completed and submitted before your child begins camp.</td>
</tr>
<tr bgcolor="#ffffff">
<td bgcolor="#ffffff">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Name on Card</strong></strong></div>
</div>
</td>
<td class="regular_text" bgcolor="#ffffff" colspan="7">
<input tabindex="1" id="x_name" class="Form_Text_box" required="true" name="x_name" type="text"></td>
</tr>
<tr bgcolor="#ffffff">
<td bgcolor="#ffffff">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Card Number</strong></strong></div>
</div>
</td>
<td class="regular_text" bgcolor="#ffffff" colspan="7">
<input tabindex="1" class="Form_Text_box" autocomplete="OFF" required="true" name="x_card_num" type="text"></td>
</tr>
<tr bgcolor="#ffffff">
<td bgcolor="#ffffff">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>
<strong>Expiration</strong></strong></div>
</div>
</td>
<td class="regular_text" bgcolor="#ffffff" colspan="7" style="font-size: 10px; font-family: Arial">
<select tabindex="1" class="regular_text" name="x_exp_month">
<option value="01" selected>01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select><select tabindex="1" class="regular_text" name="x_exp_year">
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
</select></td>
</tr>
<tr bgcolor="#ffffff">
<td bgcolor="#ffffff" width="90">
<div class="regular_text" align="right">
<div class="regular_text" align="right">
<strong>CVV Code</strong></div>
</div>
</td>
<td class="regular_text" bgcolor="#ffffff" colspan="7" style="font-size: 10px; font-family: Arial">
<p>
<input tabindex="1" class="Form_Text_box" maxlength="4" required="true" name="x_card_code" type="text"><span style="color: rgb(0,0,0)">
<a onclick="window.open('/tools/donate/CVVInfo.htm','CVVInfo','width=440,height=480,resizable=no,status=no,scrollbars=yes'); return false;" href="https://www.mychabad.org/admin/Publishing/&amp;DocType=Form#">
<span style="font-size: 9px">
<font color="#0000ff">What's This?</font></span></a></span></p>
</td>
</tr>
<tr>
<td bgcolor="#BEDAFF" valign="top" width="90" style="text-align: right">
<input tabindex="1" type="checkbox" name="authorize" value="on"></td>
<td class="regular_text" bgcolor="#BEDAFF" colspan="7">
<strong>I authorize Camp Gan Israel to charge my card registration fees in the amount of $ <select tabindex="1" class="regular_text" name="x_amount">
<option value="$75" selected>1 camper $75</option>
<option value="$150">2 campers $150</option>
<option value="$225">3 campers $225</option>
</select></strong></td>
</tr>
<tr>
<td bgcolor="#ffffff" valign="middle" width="90">
<div align="right">
<div align="right">
<span class="regular_text" style="font-size: 7pt">•</span></div>
</div>
</td>
<td class="regular_text" bgcolor="#ffffff" colspan="7"><span style="font-size: 9pt">I have read and agree to the <a target="_blank" href="/Article.asp?AID=1097783">
<strong>terms and conditions</strong></a>. I authorize Camp Gan Israel, to have my child treated in case of emergency by a physician in the manner such person deems necessary. I further give permission for my child to attend and be transported on camp trips.</span>
<br>
            Please type your name here: <input tabindex="0" class="Form_Text_box" required="true" name="I agree to terms and conditions" type="text"></td>
</tr>
<tr>
<td bgcolor="#BEDAFF" width="90"> </td>
<td class="regular_text" bgcolor="#BEDAFF"> </td>
<td class="regular_text" bgcolor="#BEDAFF"> </td>
<td class="regular_text" bgcolor="#BEDAFF"><strong>Date of Application</strong>: <input tabindex="0" id="Date" class="Form_Text_box" required="true" name="Date_of_Application" type="text"></td>
<td class="regular_text" bgcolor="#BEDAFF" colspan="4">Discount Code: <br>
<span style="font-size: 13px;">(*one per family, restrictions may apply)</span><br>
<input tabindex="1" class="Form_Text_box" placeholder="Optional" name="Discount Code" type="text"></td>
</tr>
</tbody>
</table>
<p> </p>
    </div>


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