Lubavitch Day Camp Monsey
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Primary Contact for account

Enter the information for the primary contact for this account. This person must be an adult.
First Name:

Last Name:

Middle Initial:
Nickname:
Gender:
Address:

City:

State / Province:
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Zip / Postal Code:

Primary Phone
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Alternate Phone:
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Ext.



Alternate Phone 2:



E-mail Address:
*
Confirm E-mail Address:
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Roles:
Please check all that apply


Additional Contact for account

Add an additional contact for this account by completing the information below.
This person is:
First Name:
Last Name:
Middle Initial:
Nickname:
Gender:
Address:
 
City:
Sate / Province:
Zip / Postal Code:
Primary Phone:


Alternate Phone:
Alternate Phone Ext:

Alternate Phone 2:

E-mail Address:
Confirm E-mail Address:

Roles:
Please check all that apply





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The username and password must consist only of letters and/or numbers.  No special characters or spaces are allowed.
Username:
Password:
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Confirm Password:
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23 Calvert Dr #201 • Monsey • NY • 10952 • 845-418-5170
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