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Keren Yisroel Ukraine

Parent's Information

Please fill out ALL information correctly (Including address, phone numbers and email addresses).
Father's Name*

First Name Last Name
Mother's Name*

First Name Last Name

Current Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's Cell*

Area Code Phone Number
Mothers Cell*

Area Code Phone Number
Father's E-mail*
Mother's E-mail*
Shlichus Information
Place of Shlichus in Ukraine*
Moisad Website*
Child's Information

For more then one child, please submit another form
Child's Name*

First Name Last Name
Gender*

Male Female
Birth Date*

Month Day Year
Camp Information
Camp your child is attending*
Amount of weeks your child will be attending camp*
Your camp bill for this child*
Questions or Comments
Should be Empty:

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