REGISTRATION FORM

Today’s date:

Camper Information

Camper’s last name: First:

Middle:

Grade Entering: Age: Birth date:

Sex: Jewish Name:

Best way to contact: Email Phone

Street address/PO Box/City/State/Zip:

Home phone:

Mother/Guardian Name:

Phone: Other phone:

Father/Guardian Name:

Phone: Other phone:

REGISTRATION OPTIONS (please check all that apply)

Week 1: July 2 – July 6 $150

Before/After Care 7:30-9:30 a.m./ 3:30- 5:30 p.m. $7/hour Please specify days and times

Week 2: July 9h – July 13 $150

Before/After Care 7:30-9 a.m./ 3:30- 5:30 p.m. $7/hour

Please specify days and times

 Week 3: July 15 - July 20 $150

 

Weeks 1 and 2: July 2 - July 13$275

Weeks 1 - 3: July 2 -July 20   $400

Scholarship Fund

Yes I would like to apply for a scholarship for my child/children

This is the amount I am able to pay per week

Scholarships are run on first come basis, and given out based on availability, you will be informed as soon as possible as to the amount available for your child - Your card will not be charged until scholarship amount is confirmed.

I am sending a non-refundable payment of $

payable to Chabad Charlotte County.

Please charge $ to my credit card:

Visa MC Discover

Card number Expiration Date

Security Code

ADDITIONAL EMERGENCY CONTACT OTHER THAN PARENT

Emergency Contact

Name: Relationship:

Phone #1 Phone #2

All other individuals authorized for pick up (will be required to show photo ID:

1. Name:

Relationship: Phone

2. Name:

Relationship: Phone

3. Name:

Relationship: Phone

Parental Consent

I hereby permit my child to participate in all activities of Camp Gan Israel – on-site, off-site and trips. I understand that my child may be dismissed during a camp day, due to illness, at the discretion of the camp, and I agree to abide by the director’s decision. The parent who submits this registration form represents that s/he has full authority to do so and will be responsible for payment of the camp fees.

Parent/Guardian e signature:

Date: