Registration

Home address:*

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?
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

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Camper 1: