Step 1: Camper Information |
Camper's Last Name:
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Camper's First Name:
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Birth date:
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Gender:
Male
Female |
Address:
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City:
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State:
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Zip Code:
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Home Phone:
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School:
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Grade Entering September 2012:
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Mother's Title: (Mrs., Miss, Dr., etc)
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Father's Title: (Mr., Dr., Rabbi, etc)
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Mother's Name:
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Father's Name:
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Mother's Cell Phone:
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Father's Cell Phone:
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Mother's Work Phone:
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Father's Work Phone:
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Mother's Email Address:
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Father's Email Address:
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Is mother a full-time teacher in the ATT system?
Yes
No |
Is father a full-time teacher in the ATT system?
Yes
No |
If yes, school name:
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If yes, school name:
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Step 2: Camper Medical Information |
Child's Physician:
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Physician's Phone:
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Name of Insurance Company:
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Group Info:
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Policy #:
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Emergency Contact (If Parents are Unavailable):
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Emergency Contact's Phone (If Parents are Unavailable):
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Relationship to Child:
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| Does your child have any special medical conditions (i.e. asthma, allergies, medications, etc.)? |
No
Yes
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If yes, please explain and mail Medical Action Plan (MAP) to ATT:
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I hereby authorize the Associated Talmud Torahs to provide emergency care should it be necessary.
I hereby permit my child to go on excursions off the premises with authorized ATT staff members.
My child has permission to:
Walk Home
Bike Home
Carpool Home |
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Step 3: Class Registration |
Session 1:
Gender:
Boy
Girl
Has a sibling already registered for ATT Summer Program?:
Yes
No
Grade Entering September 2012:
1
2
3
4
5
6
7
8
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Session 2:
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Step 4: Deposit Information |
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Application will not be accepted without a $100.00 deposit. |
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To pay by credit card, please call 773-973-2828 and ask for Sandra Friedman. Up to three credit card payments (Visa and MasterCard only) may be made. Please specify dates on which payments should be processed when speaking to Sandra. |
To pay by check, please mail check to: ATT, 2828 West Pratt, Chicago, IL 60645. ATTN: Sandra.
Please make deposits and post-dated checks payable to the ATT Summer Program. Bring or mail checks to:
ATT Summer Program
Attention: Sandra
2828 West Pratt Blvd.
Chicago, IL 60645
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