Winter Camp Registration

Parent Information
Please reach out to manya@chabadofdallas.com with any questions or concerns with this registration form.
Parent 1:
Parent Full Name*

First Name Last Name
Cell*
E-mail*

Address*

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

Parent 2:
Parent Full Name*

First Name Last Name
I would like to receive news and updates by email
Cell*
E-mail*
FEES:
$45/day per child; $40/day per child for full week.
How many campers are you registering*
CAMPER INFORMATION:
Camper Full Name

First Name Last Name
Grade*
Gender*
Birth Date

Month Day Year
School Attending
Days Attending*

Monday, December 21st Tuesday, December 22nd Wednesday, December 23rd Thursday, December 24th Friday, December 25th Whole Week
Medical Questionaire
Has your child had any recent surgery or illness?*

Yes No
If yes please specify
Does your child have allergies? (food or medication)*

Yes No
If yes please specify
Does your child take medication regularly?*

Yes No
If yes please specify
Is your child current on his/her immunizations?*

Yes No
May we give Tylenol or Benadryl if needed?*

Yes No
Are there any medical concerms that your child's counselor should be aware of?*

Yes No
If yes please specify
Emergency Contacts
Emergency Contact Full Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Relationship to child*
Emergency Contact 2:
Full Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to child
Permission
I herby give permission for my child to participate in all camp activities. In addition i give Camp Gan Israel permission (a) to render necessary first aid or to arrange care by medical personnel, if deemed neccesary; (b) To use photographs and videos and names of campers in printed material and websites associated with Camp Gan Israel; (c) I indemnify and hold harmless Camp Gan Israel from any liability or claim for any loss, injury, damage, or expense resulting or arising from my child's participation in camp activities; and (d) The camp administration reserves the right to reconsider the enrollment of any camper if we feel the child's needs or level of unctioning or behavior cannot be accommodated, or if the child's conducts limits his or her ability to participate in, or to benefit fully from, the programs and activities at Camp Gan Israel.
Parent Guardian*
Registration is confirmed with a minimum of $40 deposit per child. The balance is due by December 17th.

Until December 16th- 100% refund. December 17th-22nd 50% refund. During camp - 25% refund.

In all cases the deposit is non-refundable.
Payment Options

Please charge my card in full- (you will see two seperate charges on your credit card bill reflecting the deposit and tuition) Please charge deposit now and balance on December 17

Payment

Credit Card

Credit Card Type
Credit Card Number
Name on Card
Expiration Month	Expiration Year

Additional Camper Information
Camper 2:
Full Name

First Name Last Name
Grade
Gender
Birth Date

Month Day Year
School Attending
Child 2: Days Attending

Monday, December 21st Tuesday, December 22nd Wednesday, December 23rd Thursday, December 24th Friday, December 25th Full Week
Medical Questionaire
Camper 2
Has your child had any recent surgery or illness

Yes No
If yes please specify
Does your child take medication regularly

Yes No
If yes please specify
Is your child current on his/her immunizations?

Yes No
May we give your child Tylenol or Bendaryl if needed?

Yes No
Are there any medical concerns that your child's counselor should be aware of?

Option 1 Option 2 Option 3
If yes please specify
Additional Camper Information
Camper 3
Full Name

First Name Last Name
Grade
Gender
Birth Date

Month Day Year
School attending
Child 3 Days Attending

Monday, December 21st Tuesday, December 22nd Wednesday, December 23rd Thursday, December 24th Friday, December 25th Full Week
Medical Questionaire:
Has your child had any recent surgery or illness?

Yes No
If yes please specify
Does your child take medication regularly?

Yes No
If yes please specify
Is your child current on his/her immunizations?

Yes No
May we give your child Tylenol or Benadryl if needed?

Yes No
Are there any medical concerns that your child's counselor should be aware of?

Yes No
If yes, please specify
Please scroll back up to "payment options" to submit this form.
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Parent Information

FEES:

CAMPER INFORMATION:

Medical Questionaire

Emergency Contacts

Permission

Additional Camper Information

Medical Questionaire

Additional Camper Information

Medical Questionaire: