Skip to content

Bnot Shirah

Bnot Shirah Application

This field is hidden when viewing the form

Current Unix Epoch

This field is hidden when viewing the form

date:

This field is hidden when viewing the form

Camp Office Email

This is the email address for the camp's office

Application For New Enrollment 26-27/תשפ"ו-תשפ"ז

Incoming primary student must be 5 years old before October 1, 2026.

Student Entering Grade*

Student

Last Name:*

First Name:*

Hebrew Name:*

Date of Birth (English)*

Current School Child is Attending:*

Current Morah's Name:*

Current Morah's Number*

Parents' Marital Status*

Shul Affiliation*

Rabbi*

Family Rabbi*

Phone Number*

Language spoken at home*

English

Hebrew

Other

Does your child understand or speak another language? Please specify:*

This field is hidden when viewing the form

Camper Full Name

Contact Information

Home Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Mother

Maiden Name*

Mother's First Name:*

Mother's Hebrew Name (Hebrew Spelling Please)*

Mother's Place of Birth*

Mailing Title (please check one)

Rebbetzin

Mrs.

Dr.

Cell Phone #:*

Allow Text - To opt out reply stop at any time*

Yes

No

Work Phone #:*

Email*

Occupation:

*

Owner

Employee

HIgh School /Seminar /College Attended*

Father

Father's First Name*

Father's Hebrew Name (Hebrew Spelling Please)*

Father's Place of Birth*

Mailing Title*

Rabbi

Mr.

Dr.

Father's Cell*

Allow Text - To opt out reply stop at any time*

Yes

No

Work #*

Email*

Occupation

*

Owner

Employee

Yeshivot or School's Attended*

Grandparents

Relationship

Last Name*

Grandfather's Title*

Grandfather's Name*

His Cell*

Email*

Grandmother's Title*

Grandmother's Name*

Her Cell*

Her Email*

Home Phone Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

Last Name*

Grandfather's Title*

Grandfather's Name*

His Cell*

His Email*

Grandmother's Title*

Grandmother's Name*

Her Cell*

Her Email*

Home Phone Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Siblings

First Name*

Date*

Gender*

School*

Is your child currently receiving any special services:*

Yes

No

Please check the appropriate box:*

Speech

OT

PT

Counseling

Kriah

P3

SEIT

Other

Does your child have an IEP?*

Yes

No

Please attach*

Max. file size: 20 MB.

Any serious illness?*

Yes

No

Please Specify*

Any physical handicap?*

Yes

No

Please Specify*

Any allergies?*

Yes

No

Please specify and how severe.*

Does your child take any medication?

Yes

No

Please Specify*

Where do you spend the summer?*

Which summer camp does your child attend?*

Family Pediatrician*

Pediatrician's Phone Number:*

Consent*

I hereby certify that the information given in this application is completed and true.*

There is a $300 charge to submit the application.*

For Office Use

Due Now:

Price: $550.00

Credit Card*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Signature of Father:*

Your Name
Your Name
Your Name

Signature of Mother:*

Your Name
Your Name
Your Name

Δ

|