You may register your children for Camp via the online form, below!  If you would prefer to submit the application by hand, click HERE for a printable version.  Send payments to: Camp Shalom c/o Patti Brownstein, 3354 Barrow Hill Trail, Tallahassee, FL 32312.

Child 1's Name*

Choose Week(s)

Grade Entering Fall 2017*

School*

Date of Birth*

Sex*

Child 2's Name

Choose Week(s)

Grade Entering Fall 2017

School

Date of Birth

Sex

Mailing Address

Parent's Names*

Parent 1's Phone*
 Cell Work Home

Parent 1's Email Address*

Parent 2's Phone
 Cell Work Home

Parent 2's Email Address

Affiliation
Temple Israel Shomrei Torah Other 

Are you a current Tallahassee Jewish Federation Member?
Yes No 

Emergency Contact's Name

Emergency Contact's Relationship to Camper

Emergency Contact's Phone
 Cell Work Home

Alternate Persons Authorized to Pick Up Camper

Alternate 1's Name

Alternate 1's Phone
 Cell Work Home

Alternate 2's Name

Alternate 2's Phone
 Cell Work Home

HEALTH INFORMATION

Medications Taken Regularly

Allergies

Health Insurance Company Name

Health Insurance Company Policy #

Physician's Name

Physician's Phone

PARENTAL AUTHORIZATION FOR EMERGENCY TREATMENT

Should my child become ill or suffer an accident during the time that he/she is in the care of Camp Shalom, the camp will contact me immediately. In the event that the camp is unable to reach me immediately, I authorize Camp Shalom to secure medical attention for my child as may be necessary.
Yes No 

PARENTAL AUTHORIZATION FOR PICTURES

Do you give your permission to have your child's picture taken and displayed at Camp Shalom or on the Camp Shalom website?
Yes No 

What is your child's t-shirt size? Each camper will receive a free Camp Shalom t-shirt.
Child 1:
Child 2:

Is there anything special we should know about your child? Can he/she participate in all camp activities?

AFTER CAMP - 3:00 - 5:30pm (Monday - Friday)

My child will attend after-camp on the following days (Check all that apply):
Mon. 6/5 Tues. 6/6 Wed. 6/7 Thurs. 6/8 Fri. 6/9 Mon. 6/12 Tues. 6/13 Wed. 6/14 Thurs. 6/15 Fri. 6/16