1. Participant Information Summer Application From The summer program is a month long program featuring an exciting mix of learning, camping, hiking, sightseeing, sports, mixed martial arts and more. Dates: July 9th - August 6th Ages: 16 + Cost: $2,800 Spaces are limited, so please confirm acceptance with Uri Perlman and then register by completing the form below. For more information please call or whatsapp Uri Perlman at 570-239-4348 or email him at [email protected] Participant Name* First Name Middle Name Last Name E-mail* Number* Area Code Phone Number Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Social Security Number* Status in the U.S. U.S. CitizenPermanent ResidentNeeds Student VisaOther 2. Parent information Father's Info* First Name Last Name E-mail* Primary email Cell Phone* Area Code Phone Number Mother's Info* First Name Last Name E-mail* Cell Phone* Area Code Phone Number Marital Status* MarriedSeparatedWidowedDivorced 3. Emergency Information Emergency Contact* First Name Last Name Phone Number* Area Code Phone Number Relationship* Primary Care Physician* First Name Last Name Phone Number* Area Code Phone Number Insurance* Policy #* Please list any medical conditions including allergies (food, medicine, other), asthma, health conditions, chronic illness, psychological conditions, etc.: Please upload copies of front & back of participant's insurance card or email to [email protected] Application will not be considered complete until insurance cards have been submitted. 4. Payment Information Tuition must be paid in full or a payment plan arranged by July 9, 2025 Program Fee* $2800 USD Payment* Credit Card Paypal Payment Plan, Wire, Check Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2025202620272028202920302031203220332034 Expiration YearPaypal has been selected. Payment will take place on the next page. Total $0.00 USD Agreement* I certify that the above information is acurate and authorize Bais Menachem to use the medical information provided above in the case of an emergency Additional comments Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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