Camp Registration

Today’s date:*

Camper’s name*

First Name Last Name

Middle name:

Grade Entering:*

Age:*

Birth Date*

Month Day Year

Sex*

Male Female

Jewish Name:*

Best way to contact:*

Email Phone

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

Please check all that apply*

Week 1: July 5 – July 8 $150 Week 2: July 11 – July 15 $150 Week 3: July 18 - July 22 $150

Number of before/after care hours needed:

$7/hour

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

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

Amount to charge now:*

$

Please charge my balance:*

In one payment In three equal payments

Total

$0.00

Payment*

Credit Card Check

Postal / Zip Code

Country

Emergency Contact Name:*

First Name Last Name

Relationship:*

Phone #1:*

Area Code Phone Number

Phone #2:

Area Code Phone Number

1. Name:

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

2. Name:

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

3. Name:

First Name Last Name

Relationship:

Phone Number

Area Code Phone Number

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 signature:*

Date:*

Camper Information

REGISTRATION OPTIONS

Scholarship Fund

Additional Emergency Contact Other Than Parent