Registration

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

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

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:*

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:

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?

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

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:

Camper 1:

Camper 2:

General Information:

Parent Information:

Emergency Contact Information:

Permission:

Payment Details: