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Register Online!

Register Online!

Please fill out the form below carefully. When you press submit, this form will be sent to our administration office.

Note: Please use a separate form for each child.

Camper/Parent Information
Name
  First
Middle
Last
Hebrew Name
Address
  Street
City
State
Zip
Date of Birth
  Boy
Girl
Contact Info
  Fathers Email
Mothers Email
Home Phone Full
Season 1
Season 2
    School
Age:
Grade completed this June
Child's Mother
  Name
Hebrew Name
Work Phone
Cell

Carrier

Child's Father
  Name
Hebrew Name
Work Phone
Cell

Carrier
Marital Status
  Child resides with:
   
Persons authorized to pick up camper
  #1 Name

Phone Number
#2 Name

Phone Number
#3 Name

Phone Number
#4 Name

Phone Number
Emergency Contact Info 1
  Name
Phone
Relationship
 
Emergency Contact Info #2 1
  Name
Phone
Relationship
 
           
 
Medical/Health Information
Family Physician
  Name
Phone
Insurance Policy
Policy#
Medication
  Medication that your child takes regularly:
Will this medication need to be dispensed at camp?
Yes No

If yes please explain

Health Issues
  Special dietary needs or restrictions:
Any recent surgery or serious illness:
List any allergies (food or medication)
    Is your child prone to:
Ear infection Sinus infection
Other please explain
Does your child have any mental or social handicap or any other problem of which we should be aware in caring for him/her?
 
 
General Information:
Camper Info
  Camper’s strong likes and dislikes
Camper makes friends:
Easily
Fairly well
With difficulty
How does your child feel about going to camp this summer?
Camper Info
  Are there any special situations or difficult transitions in your Child’s life (i.e.-moving, school, changes in family situations, etc.)? It is important for your child that you use this space to share this information with us What is the most important thing that you would like us to know about your child?
Family Info
  Are the natural parent’s of the child/ren Jewish?
Mother Father
Any conversions or adoptions in the family?
Yes No
If yes please explain:
Affiliation
  Are you affiliated with any Synagogue? Yes No
Name
Does your child attend Hebrew school? Yes No
If yes name
Swimming Info
  Does your child swim? Yes No Does your child have fear of water? Yes No Explain:
T-Shirt Info
  I would like to buy T Shirts at $10.00 a T Shirt T-shirt size 6-8 10-12 14-16
Adult S Adult M Adult L
    Elective details coming soon both
 
Payment Information:
Payment type
  Visa Master Card If paying by CC you need to add a 3% convenience processing fee. You can avoid this and not lose your filled application  by making small cc payment and mailing a check for the rest. Cardholder's First Name Last Name
Credit Card Info
  Number
Expiration Date
Amount to charge: 4 CVV
         
 
Comments:

Where did you hear about Camp Gan Israel?

     
 
IMPORTANT
I will mail or bring in a copy of my child’s immunization records and child’s health examinations forms (blue and Yellow). Registration is not complete without this.
I give my permission to use the photograph of my child as well as myself for promotional purposes. Camp group list can be disseminated with campers and parents names and phone numbers.
My child has my permission to participate in Camp Gan Israel Day Camp. I understand that this program includes field trips and activities off the premises.
I understand that in case of emergency and I am unable to be contacted, I give permission to Camp Gan Israel to authorize any emergency action necessary to insure the safety of my child.
I understand that by participating in any Camp Gan Israel activities and use of any recreational facilities involves risk of accidental injury despite all safety precautions. Having been informed of the activities to be conducted by the Camp Gan Israel, I/ We as an individual or as a parent or guardian of the participants named herein, assume all risk and hazards incidental to the activities and release from responsibility and agree to indemnify and hold harmless the Camp Gan Israel, its officers, directors, independent contractors, volunteers and all employees for any illness or injury to me or my children or family members occurring during his/her/our participation in any activities or use of any facilities at or conducted by Camp Gan Israel.
I understand that all deposits are non refundable.
I understand that by enrolling in Camp Gan Israel I am agreeing to abide by all its policies.
I have read the parent handbook and application form and agree to the terms stated.
 
 
   
  Date of Application: Initials:

 

1 Please note: these numbers are needed in event of an emergency.
2 Actual shirt sizes run small (e.g. if you need a 10-12 size order 14-16 etc.)
3 Registration not complete until 50% deposit is received. (Unless other arrangements have been made). Full payment is required by May 23rd.
4 Please include total for tuition and T shirt fee, Thank you. For rates click here.

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