2007 Camper Application

Camper's Name

Phone Number

Address

City

State

Zip Code

Date of Birth

Sex

Male

Female

Grade Completed as of Fall 2007

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 - Until Jan. 15

2005 - After Jan. 15

Full: 6/24-8/16

$5100

$5600

1st Session: 6/24-7/19

$2800

$3100

2nd Session: 7/22-8/16

$2600

$2900

Mini Session A: 6/24-7/5

$1550

$1750

Mini Session B: 7/8-7/19

$1550

$1750

Mini Session C: 7/22-8/2

$1550

$1750

Full: 6/24-8/16 (w 2 overnight trips)

$5400

$5600

1st Session: 6/24-7/19 (w\ 1 overnight trip)

$3000

$3200

2nd Session: 7/22-8/16 (w\ 1 overnight trip)

$2800

$3000

Mini Session A: 6/24-7/5

$1750

$1850

Mini Session B: 7/8-7/19

$1750

$1850

Mini Session C: 7/22-8/2

$1750

$1850

Full: 6/24-8/16 (w Two 3- day\2-night trips)

$6000

$6400

1st Session: 6/24-7/19 (w\ One 3-day\2-night trip)

$3300

$3500

2nd Session: 7/22-8/16 (w\ 1 overnight trip)

$3200

$3400

Full: 6/24-8/16

$3900

$4200

1st Session: 6/24-7/19

$2300

$2500

2nd Session: 7/22-8/16

$2200

$2400

DISCOUNTS

CQY New Member - Take $200 off any regular session if registered by Jan. 15th

Less Applicable
Discounts =

Subtotal =

Deposit 
(min $300) =

Balance Due =