Camp Limmud AZ Registration Form

Child #1

Name Age Grade in School
Does your child wear diapers or pull-ups? Yes No 
Does your child have allergies? Yes No  Please list:


Child #2

Name Age Grade in School
Does your child wear diapers or pull-ups?  Yes No
Does your child have allergies?  Yes No Please list:


Child #3

Name Age Grade in School
Does your child wear diapers or pull-ups?  Yes No
Does your child have allergies?  Yes No Please list:


Child #4

Name Age Grade in School
Does your child wear diapers or pull-ups?  Yes No
Does your child have allergies?  Yes No Please list:


Child #5

Name Age Grade in School
Does your child wear diapers or pull-ups?  Yes No
Does your child have allergies?  Yes No Please list:


Total number of kids in Camp Limmud:


Parent contact information (please print clearly):

Parent(s) Name Your Email Contact Phone


Emergency contact information during the program:

Contact NameRelationship to children Contact Phone:

Contact NameRelationship to children Contact Phone: