2010 Summer Day Camp Registration Application
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Mishkan Israel Day Camp
77 Mt. Pleasant Dr. Trumbull, CT 06611
Phone: (203) 268-0740 OR (203)
268-2374
Preschooler [ ] School Age [ ] Boy [ ] Girl [ ]
Week Beginning __________________ Week Ending ________________
Day Beginning ___________________ Day Ending__________________
Surname ________________________ First Name__________________
Address ___________________________________________________
City____________________State__________Zip___________________
Phone(s) Home _____________Work _______________Cell _________
Age as of June 2010 ________________ D/O/B ___________________
Hebrew Name (If applicable) _________________ Nickname_________
Father’s Name _____________________ Mother’s Name ____________
School ___________________ Public ( ) Hebrew ( ) Yeshiva ( )
Grade in now ___________________ Grade for coming year _________
Family Doctor __________________ Phone_______________________
Alt. Family Doctor ________________Phone ______________________
List any & all
allergies_________________________________________
(Use separate sheet if necessary)
In case of emergency, God forbid, contact _________________________
Relationship _____________________ Phone______________________
If an emergency arises, God forbid, and none of the above numbers can be contacted, I hereby give the Mishkan Israel Day Camp full permission to take whatever measures it feels necessary to remedy the situation.
I hereby give my child/children my full permission to go on all trips & outings with Mishkan Israel Day Camp at all times.
Signed__________________________ Date________________________