« Back to Chabad of the Conejo | Conejo Jewish Academy

Register

Kiddy Camp: Ages 3-4

Camper's Info
Full Name*
First NameLast Name
Birth Date*
MonthDayYear
Gender*
Known Allergies*
Contact Info
Parent Name*
First NameLast Name
Phone Number*
Area CodePhone Number
E-mail*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact*
First NameLast Name
Emergency Contact Phone Number*
Area CodePhone Number
Relationship to Emergency Contact*
Payment
Sign up for 4 Weeks/$600
YesNo
Sign up Weekly / $175 per week
Amount of weeks
Sign up Daily / $60 per day
Amount of days
Add Hot Lunches / $5 per day
Amount of hot lunchs
Total
$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

This page uses TLS encryption to keep your data secure.