Camp Application

Child's Name*
Date of Birth*
Age Group*
Gender*
Number of weeks going to camp*
Which weeks will you attend? (Enter dates below)*
Address, Apt Number, Zip Code*
Phone Number*
Parent #1 Name*
Phone*
Email*
Occupation*
Parent #2 Name*
Phone*
Email*
Occupation*
Emergency Contact Name/Number*
Names of people who are authorized to pick up your child.*
Does your child have allergies?*
If yes, what is your child allergic to?
Has your child had previous nursery school experience? Where?*
What special talents/special needs/learning challenges does your child have?*
Has your child been evaluated for any special needs?*
If yes, when and by whom was the evaluation done? What were the results, including any medication prescribed?*
What would you like us to know about your child that will help us make this a happy and fulfilling camp experience?*
Signatures: I/We understand to hold a spot in camp you must pay a $250 deposit. We further agree to fulfill all payment policies and abide by all policies set forth by Riverdale Temple Nursery School/Camp.*

	administrator@riverdaletemple.org
	P: (718) 548-3800 F: (718) 543-1492
	4545 Independence Avenue Bronx, New York 10471