Register

Parent Information:
Parent 1 name*

First Name Last Name
Relationship to camper(s)*

MotherFatherGuardian
Work phone

Area Code Phone Number
Cell phone

Area Code Phone Number
E-mail
Parent is

Born JewishJewish through conversionNot Jewish
Parent 2 name

First Name Last Name
Relationship to camper(s)

MotherFatherGuardian
Work phone

Area Code Phone Number
Cell phone

Area Code Phone Number
E-mail
Parent is

Born JewishJewish through conversionNot Jewish
Parents' Status: *

MarriedWidowedDivorcedSeparated
Home phone:*

Area Code Phone Number

Home address: *

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

Number of Children Registering for:*
Camper 1:
Full Name*

First Name Last Name
Date of birth: *

Month Day Year
Gender:*

MaleFemale
School attending:*
Entering grade:*
Attending:* one time fee

June 26 - June 30: $375 (Subsidized Tuition)July 3 - July 7: $375 (Subsidized Tuition)June 26 - June 30: Full Tuition - $449July 3 - July 7: Full Tuition - $449
Early Care Options: 8:00 am - 9:00 am - $60 per week

Week 1Week 2Both Weeks
After Care Options: 3:00 pm - 5:00 pm - $90 per week

Week 1Week 2Both Weeks
I would like to order an extra camp shirt Each child receives one complimentary shirt needed for trip day

Yes - $10
I would like to order Hot Lunches for my child

1 Week $352 Weeks $70
Does your child suffer from any diseases or illnesses?*

YesNo
Are your child's immunizations current for the State of California's school requirements?*

YesNo
Does your child have any behavioral, emotional, physical, or mental health issues that we should be aware of?*

YesNo
Please describe the disease, illness, allergies, and/or behavior concerns.
Camper 2:
Full Name

First Name Last Name
Date of birth:

Month Day Year
Gender:

MaleFemale
School attending:
Entering grade:
Attending: one time fee

June 26 - June 30: $375 (Subsidized Tuition)July 3 - July 7: $375 (Subsidized Tuition)June 26 - June 30: Full Tuition - $449July 3 - July 7: Full Tuition - $449
Early Care Options: 8:00 am - 9:00 am - $60 per week

Week 1Week 2Both Weeks
After Care Options: 3:00 pm - 5:00 pm - $90 per week

Week 1Week 2Both Weeks
I would like to order an extra camp shirt Each child receives one complimentary shirt needed for trip day

Yes - $10
I would like to order Hot Lunches for my child

1 Week $352 Weeks $70
Does your child suffer from any diseases or illnesses?

YesNo
Are your child's immunizations current for the State of California's school requirements?

YesNo
Does your child have any behavioral, emotional, physical, or mental health issues that we should be aware of?

YesNo
Please describe the disease, illness, allergies, and/or behavior concerns.
Camper 3:
Full Name

First Name Last Name
Date of birth:

Month Day Year
Gender:

MaleFemale
School attending:
Entering grade:
Attending:* one time fee

June 26 - June 30: $375July 3 - July 7: $375June 26 - June 30: Full Tuition - $449July 3 - July 7: Full Tuition - $449
Early Care Options: 8:00 am - 9:00 am - $60 per week

Week 1Week 2Both Weeks
After Care Options: 3:00 pm - 5:00 pm - $90 per week

Week 1Week 2Both Weeks
I would like to order an extra camp shirt Each child receives one complimentary shirt needed for trip day

Yes - $10
I would like to order Hot Lunches for my child

1 Week $352 Weeks $70
Does your child suffer from any diseases or illnesses?

YesNo
Are your child's immunizations current for the State of California's school requirements?

YesNo
Does your child have any behavioral, emotional, physical, or mental health issues that we should be aware of?

YesNo
Please describe the disease, illness, allergies, and/or behavior concerns.
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:*
Comments:
Emergency Contact Information:
Contact 1:*
Phone Number*

Area Code Phone Number
Relationship to child: *
Contact 2:*
Phone Number*

Area Code Phone Number
Relationship to child:*
Family physician:*
Physician's phone number:

Area Code Phone Number
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
*

I have read through the Covid19 Procedure and will sign a waiver before my child enters camp
Parent/Guardian:*
Date:

Month Day Year
Payment Details:
Registration is confirmed with minimum of $75 deposit per child. Please indicate when you would like us to charge the additional amount. Payment is needed in full before June 26.

No tuition will be refunded due to absences.
Optional Donation I'd like to subsidized a child's tuition

$225 - 2 weeks of camp subsidy$112.5 - 1 week of camp subsidy
Total

$0.00

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

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Notes/Comments:
Should be Empty:

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Parent Information:

Camper 1:

Camper 2:

Camper 3:

General Information:

Emergency Contact Information:

Permission:

Payment Details: