Camp Registration

Today’s date:

Camper’s name*

First Name Middle Name Last Name

Jewish Name: *

Middle name:

Grade Entering:*

Age*

Age:

Birth Date*

Month Day Year

Sex*

MaleFemale

Best way to contact:*

EmailPhone

E-mail*

Phone Number*

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother/Guardian Name:*

First Name Last Name

Phone Number:*

Area Code Phone Number

Other phone:

Area Code Phone Number

Father/Guardian Name:*

First Name Last Name

Phone Number:*

Area Code Phone Number

Other phone:

Area Code Phone Number

Emergency Contact Name:*

First Name Last Name

Relationship: *

Phone #1:*

Area Code Phone Number

Phone #2:

Area Code Phone Number

Additional individuals authorized for pickup

1. Name:

First Name Last Name

1. Relationship:

1. Phone Number

Area Code Phone Number

1. Drivers License

2. Name:

First Name Last Name

2. Relationship:

2. Phone Number

Area Code Phone Number

2. Drivers License

3. Name:

First Name Last Name

3. Relationship:

3. Phone Number

Area Code Phone Number

3. Drivers License

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.
I grant permission to CGI, its agents, and its employees to produce photographs and video taken of my child, myself, and members of my family while at CGI for any lawful purpose including publication, promotion, illustration, advertising.

*

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.I grant permission to CGI, its agents, and its employees to capture and produce photographs and video taken of my child, myself, and members of my family while at CGI for any lawful purpose including publication, promotion, illustration, advertising.

Parent/Guardian signature:*

Date: *

How many weeks will you be joining?*

1 week $1752 weeks $3253 weeks $475

Which week will you be joining?*

Week 1: July 22– 26Week 2: July 29 – August 2Week 3: August 5 - 9

Which week will you be joining?*

Week 1: July 22– 26Week 2: July 29 – August 2Week 3: August 5 - 9

Which week will you be joining?*

Week 1: July 22– 26Week 2: July 29 – August 2Week 3: August 5 - 9

I will need:

BeforeAfterBoth

Number of before/after care hours needed:

$7/hour

Would you like to apply for a scholarship for your child/children

YesNo

Would you like to apply for a scholarship for your child/children*

YesNo

This is the amount I am able to pay per week:

Amount to charge now:*

$

Please charge my balance:*

In one paymentIn three equal payments

Total

$0.00

Payment*

Credit Card Check

Postal / Zip Code

Country

Camper Information

Parent/Guardian Information

Emergency Contact Other Than Parent

Additioinal Individuals Autherized For Pick UP

Parental Consent

PAYMENTS OPTIONS

Before/After Care: 7:30 - 9:00 a.m. / 3:00 - 5:30 p.m.

Scholarship Fund