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It is preferable to complete this form in Hebrew / Please complete a separate form for each camper /

FULL NAME OF PARTICIPANT NAME OF PARENT FULL ADDRESS PARENT’S HOME TELEPHONE PARENT’S CELL PARENT’S EMAIL -

PAYMENT SCHEDULE
The price of Camp Amichai is 6,150 NIS. Of that, 1,000 NIS must be paid upon application. The balance is to be paid by the end of June 2012. Sibling discount: deduct 180 NIS for each additional child. Discount for siblings Additional deduction (if arranged) . . 1000 .6/2012 . 6,150 : : 180 :

___________ NIS ___________ NIS ___________ NIS

Names of siblings ____________________________________

TOTAL PAYMENT
" Card Name on Card Credit Card No. Expiry Date (MM/YY) Last three digits on back the card Amount of payments

Mastercard

Visa

/

1

2

3 Comments

Amount
DEPOSIT /

Month to be deducted

Day to be deducted 1st 1st 1st 1st 10th 10th 10th 10th

1 2 3 4

1000

: " . , Acceptance onto Camp Amichai is conditional on full payment, and on participants and parents completing and returning the declaration of accepting the rules and guidelines prior to the start of the program. I agree to the above terms. SIGNATURE / ________________________________________________________ DATE / ____________________________________________

Please fax this form to the Camp Director at 073 219 7838 or scan and email it to camp@bneiakiva.net
camp@bneiakiva.net : 0732197838