Printed from ChabadFremont.com

Registration

Camper 1:
Full Name*
First NameLast Name
Date of birth:*
MonthDayYear
Gender:*
MaleFemale
School attending:*
Entering grade:*
Attending:*
1 session - $3652 sessions- $650
Requesting lunch/snacks:
1 session - $302 sessions- $60
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
1 session - $237.502 sessions - $427.50
Requesting lunch/snacks:
1 session - $302 sessions - $60
General Information:
Previous Camps Attended:*
How did you hear about Camp Gan Israel?*
What goals would you like to see your child/ren accomplish during camp?*
Briefly describe your child/ren's personality:*
Child/ren's favorite activities:*
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 in individual or group pictures 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.
Total
$0.00

I would like to pay today: Full amount$50.00 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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