Three days, December 28-30 at Chabad of New Mexico. $35 per day. Scholarships available. Lunch included.Parent Full Name*First NameLast NameE-mail*Phone Number*Area CodePhone NumberChild 1:*First NameLast NameBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAttending:*December 28December 29December 30In the past six months, has your child had any serious illnesses?*YesNoPlease specify:In the past six months, has your child been on any medications?*YesNoPlease specify:Child 2:First NameLast NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAttending:December 28December 29December 30In the past six months, has your child had any serious illnesses?YesNoPlease specify:In the past six months, has your child been on any medications?YesNoPlease specify:Child 3:First NameLast NameBirth Date1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearAttending:December 28December 29December 30In the past six months, has your child had any serious illnesses?YesNoPlease specify:In the past six months, has your child been on any medications?YesNoPlease specify:Please specify any special concerns/allergies/requests regarding camper(s)?Permissions:*I give permission to the staff to obtain necessary emergency medical treatment for my child with the understanding that my family will be notified as soon as possible.EMERGENCY CONTACT INFORMATIONPlease list at least one emergency contact other than the child's parents.1. Emergency Contact Name [other than parents]:*First NameLast NameRelationship to Child(ren):*Mobile:*Area CodePhone NumberTotal$0.00PaymentPlease bring check payment on the first day of camp.SubmitShould be Empty: This page uses TLS encryption to keep your data secure.