Please enable JavaScript in your browser to complete this form.Child’s First Name *Child’s Last Name *Nickname (optional)Child’s Age *Child’s School *Child’s Grade *Dates Preferred (choose all that apply) *Entire Week January 25-29 ($400)Monday, January 25 ($100)Tuesday, January 26 ($100)Wednesday, January 27 ($100)Thursday, January 28 ($100)Friday, January 29 ($100)Parent’s First Name: *Parent’s Last Name: *Address: Number and Street Name *City *State *Zip *Do you want art supplies to be shipped here? *YesNoEnter Address for Shipping Art Supplies (if applicable)Parent’s Phone (Cell) *Parent’s Phone (Home)May we text you regarding Yeshiva Break Museum Camp? *YesNo Parent’s Email Address *Questions?Submit