Parent Information:Father's name*First NameLast NameWork phoneArea CodePhone NumberCell phoneArea CodePhone NumberE-mailMother's name*First NameLast NameWork phoneArea CodePhone NumberCell phoneArea CodePhone NumberE-mailParents' Status:*MarriedWidowedDivorcedSeparatedHome phone:*Area CodePhone NumberHome address:*Street AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountryNumber of Children Registering for:*Camper 1:Full Name*First NameLast NameDate of birth:*MonthDayYear Gender:*MaleFemaleSchool attending:*Entering grade:*Attending:*one time feeJuly 4 - July 8: $312.50 (Subsidized Tuition)July 11 - July 15: $312.50 (Subsidized Tuition)July 4 - July 8: Full Tuition - $425July 11 - July 15: Full Tuition - $425Early Care Options:8:00 am - 9:00 am - $60 per weekWeek 1Week 2Both WeeksAfter Care Options:3:00 pm - 5:00 pm - $90 per weekWeek 1Week 2Both WeeksI would like to order an extra camp shirtEach child receives one complimentary shirt needed for trip dayYes - $10I would like to order Hot Lunches for my child1 Week $352 Weeks $70Camper 2:Full NameFirst NameLast NameDate of birth:MonthDayYear Gender:MaleFemaleSchool attending:Entering grade:Attending:*one time feeJuly 4 - July 8: $312.50 (Subsidized Tuition)July 11 - July 15: $312.50 (Subsidized Tuition)July 4 - July 8: Full Tuition - $425July 11 - July 15: Full Tuition - $425Early Care Options:8:00 am - 9:00 am - $60 per weekWeek 1Week 2Both WeeksAfter Care Options:3:00 pm - 5:00 pm - $90 per weekWeek 1Week 2Both WeeksI would like to order an extra camp shirtEach child receives one complimentary shirt needed for trip dayYes - $10I would like to order Hot Lunches for my child1 Week $352 Weeks $70Camper 3:Full NameFirst NameLast NameDate of birth:MonthDayYear Gender:MaleFemaleSchool attending:Entering grade:Attending:*one time feeJuly 4 - July 8: $312.50July 11 - July 15: $312.50July 4 - July 8: Full Tuition - $425July 11 - July 15: Full Tuition - $425Early Care Options:8:00 am - 9:00 am - $60 per weekWeek 1Week 2Both WeeksAfter Care Options:3:00 pm - 5:00 pm - $90 per weekWeek 1Week 2Both WeeksI would like to order an extra camp shirtEach child receives one complimentary shirt needed for trip dayYes - $10I would like to order Hot Lunches for my child1 Week $352 Weeks $70General 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 CodePhone NumberRelationship to child:*Contact 2:*Phone Number*Area CodePhone NumberRelationship to child:*Family physician:*Physician's phone number:Area CodePhone NumberAre 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*I have read through the Covid19 Procedure and will sign a waiver before my child enters campParent/Guardian:*Date:MonthDayYear 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 July 1. No tuition will be refunded due to absences.Optional DonationI'd like to subsidized a child's tuition$225 - 2 weeks of camp subsidy$112.5 - 1 week of camp subsidyTotal$0.00I would like to pay today: Full amount$75.00 minimum $ Payment*Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearNotes/Comments:SubmitShould be Empty: This page uses TLS encryption to keep your data secure.