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Register

Camper 1:
Full Name*
First NameLast Name
Date of birth:*
MonthDayYear
Gender:*
MaleFemale
School attending:*
Entering grade:*
Attending:*Earlybird Pricing Ends March 30th
1 session - $3752 sessions- $7003 sessions - $975 ($325 per week)
I would like my child to be served a hot and nutritious lunchOn trip days, lunch will be picnic style
1 session - $302 sessions- $603 sessions - $75
I would like to order an extra camp shirtEach child receives one complimentary shirt needed for trip day
Yes - $10
Camper 2:
Full Name
First NameLast Name
Date of birth:
MonthDayYear
Gender:
MaleFemale
School attending:
Entering grade:
Date of birth:
MonthDayYear
Gender:
MaleFemale
School attending:
Entering grade:
Attending:5% Sibling Discount. Earlybird Pricing ends on March 30th
1 session - $356.252 sessions - $6653 sessions - $926.25
I would like my child to be served a hot and nutritious lunchOn trip days, lunch will be picnic style
1 session - $302 sessions - $603 sessions - $75
I would like to order an extra camp shirtEach child receives one complimentary shirt needed for trip day
Yes - $10
Please send me information about early care and after care
Yes
I would be interested in a Parenting Network with Rabbi Moshe Chaya on Wednesday Mornings from 9:15 am - 10:15 am
DefinitelyPossibly
General Information:
Previous Camps Attended:*
How did you hear about Camp Gan Izzy?*
What goals would you like to see your child/ren accomplish during camp?*
Child/ren's favorite activities:*
Briefly describe your child/ren's personality:*
Parent Information:
Parents' Status:*
MarriedWidowedDivorcedSeparated
Home phone:*
Area CodePhone Number

Home address:*

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

Father's name*
First NameLast Name
Work phone
Area CodePhone Number
Cell phone
Area CodePhone Number
E-mail
Mother's name*
First NameLast Name
Work phone
Area CodePhone Number
Cell phone
Area CodePhone Number
E-mail
Comments:
Emergency Contact Information:
Contact 1:*
Phone Number*
Area CodePhone Number
Relationship to child:*
Contact 2:*
Phone Number*
Area CodePhone Number
Relationship to child:*
Family physician:*
Physician's phone number:
Area CodePhone Number
Are there any medical concerns that your child's counselor should be aware of?
Has your child been seen by a mental health professional within the last 12 months?
Permission:
I grant permission for my child(ren) to be photographed and recorded in individual or group pictures or videos which may be used by Camp Gan Israel for P.R
*
I hereby give permission for my child to participate in all Camp Gan Israel activities and trips
*
I also hereby consent to the administration of Camp Gan Israel to take whatever medical measures they deem necessary for my child, in the event of a medical emergency
Parent/Guardian:
Date:
MonthDayYear
Payment Details:
Registration is confirmed with minimum of $50 deposit per child. Please indicate when you would like us to charge the additional amount. Payment is needed in full before June 18.
No tuition will be refunded due to absences.
Total
$0.00

I would like to pay today: Full amount$75.00 minimum $

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Notes/Comments:
Should be Empty:

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Camper 1:

Camper 2:

General Information:

Parent Information:

Emergency Contact Information:

Permission:

Payment Details: