Camp ECC Mommy and Me 2018

* Child's Last Name

* Child's First Name

* Date of Birth

* Home Phone Number

* Family's Email Address

* Address

* City

* State

* Zip Code

* Mother's First Name

* Mother's Last Name

* Mother's Cell Phone

Mother's E-mail Address

Please fill out, if you would like e-mail communication to this address.

Mother's Occupation

Mother's Employer

Mother's Work Phone

Mother's Business Address

Father's First Name

Father's Last Name

Father's Cell Phone

Father's E-mail Address

Father's Occupation

Father's Employer

Father's Work Phone

Father's Work Address

Nanny's Name

Nanny's Cell Phone

Are you a congregant of Congregation Agudath Israel?

Please Select OneYesNo

* Would you like information regarding membership?

Please Select OneYesNo

* Are you members of any other congregation?

Please select oneYesNo

If so, which one?

How did you hear about us?

Comments

Total

Payment in full is required for Mom and Me at the time of registration, which includes a $50 non-refundable registration fee.

April 19,2024 /
11 Nisan 5784

April 19,2024 / 11 Nisan 5784