REGISTRATION FORM 2011 - 5771

Welcome to Camp Moshava Registration


Each camper requires a separate registration form that is to be completed only by his or her parent or guardian.  All grades refer to current school grade.

Please note:


Registration complete when deposit is received. You may call in a visa/mastercard number at 416-630-7578 or send a cheque to Camp Moshava. Confirmation of acceptance will be sent approximately 2 weeks after payment and registration form is received.

Do not press the ENTER key until form is completed  

Thank you for choosing Camp Moshava Canada.

 

When you see the question mark  please point your mouse to it for more details.

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* Required information.
PLEASE REGISTER MY CHILD IN:
Please indicate: *
Camper's Last Name *
Camper's First Name *
Home Address: *
City *
Province *
Postal Code *
Home Phone *
Date of Birth (MM/DD/YY) *
School *
School Phone#
Present Grade (until June 2011) *
Camper E-mail Address
Health Card #
Version Code (ON) or Exp Date(QC)
T-shirt Size :
1st REFERENCE NAME
1st REFERENCE POSITION
1st REFERENCE PHONE
2nd REFERENCE NAME
2nd REFERENCE POSITION
2nd REFERENCE PHONE
Does camper have any Food or Drug allergies: : *
If yes, list the specific allergy:
Does camper have any behaviour issue? *
If yes, please specify:
Father's Last Name *
Father's First Name *
Father's Profession:
Father's Business Phone::
Father's Cell Number: *
Father's E-mail Address:
Father's Fax
Mother's Last Name *
Mother's First Name: *
Mother's Profession:
Mother's Business Phone:
Mother's Cell Number: *
Mother's E-mail Address:
Mother's Fax
Please provide email address where camp information should be sent: *
Synagogue Affiliation:
Phone Number:
Parents: *
Name of Custodial Parent(s):
Camper lives with:
Custody/visitation arrangements, please explain:
Please provide us with copies of legal documentation or a letter from a...
EMERGENCY CONTACT # 1 NAME *
EMERGENCY CONTACT # 1 HOME PHONE *
EMERGENCY CONTACT #1 Business Phone
EMERGENCY CONTACT #1 Cell Phone
EMERGENCY CONTACT #1 Home Address
EMERGENCY CONTACT #1 Relationship
EMERGENCY CONTACT # 2 NAME
EMERGENCY CONTACT # 2 HOME PHONE
EMERGENCY CONTACT # 2 Business Phone
EMERGENCY CONTACT #2 Cell Phone
EMERGENCY CONTACT #2 Home Address
EMERGENCY CONTACT #2 Relationship
Please upload a recent Photograph
Mom are you an alumni of Moshava?
Mom If yes, what year(s) did you go?
Dad are you an alumni of Moshava?
Dad if yes, what year(s) did you go
I authorize the use of pictures of my child on Camp Moshava promotion items. *