Winter Camp Registration

Parent Information
Please reach out to [email protected] with any questions or concerns with this registration form.
Parent 1:
Parent Full Name*
First NameLast Name
Cell*
E-mail*

Address*

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

Parent 2:
Parent Full Name*
First NameLast 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 NameLast Name
Grade*
Gender*
Birth Date
MonthDayYear
School Attending
Days Attending*
Monday, December 21stTuesday, December 22ndWednesday, December 23rdThursday, December 24thFriday, December 25thWhole Week
Medical Questionaire
Has your child had any recent surgery or illness?*
YesNo
If yes please specify
Does your child have allergies? (food or medication)*
YesNo
If yes please specify
Does your child take medication regularly?*
YesNo
If yes please specify
Is your child current on his/her immunizations?*
YesNo
May we give Tylenol or Benadryl if needed?*
YesNo
Are there any medical concerms that your child's counselor should be aware of?*
YesNo
If yes please specify
Emergency Contacts
Emergency Contact Full Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship to child*
Emergency Contact 2:
Full Name
First NameLast Name
Phone Number
Area CodePhone 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 NameLast Name
Grade
Gender
Birth Date
MonthDayYear
School Attending
Child 2: Days Attending
Monday, December 21stTuesday, December 22ndWednesday, December 23rdThursday, December 24thFriday, December 25thFull Week
Medical Questionaire
Camper 2
Has your child had any recent surgery or illness
YesNo
If yes please specify
Does your child take medication regularly
YesNo
If yes please specify
Is your child current on his/her immunizations?
YesNo
May we give your child Tylenol or Bendaryl if needed?
YesNo
Are there any medical concerns that your child's counselor should be aware of?
Option 1Option 2Option 3
If yes please specify
Additional Camper Information
Camper 3
Full Name
First NameLast Name
Grade
Gender
Birth Date
MonthDayYear
School attending
Child 3 Days Attending
Monday, December 21stTuesday, December 22ndWednesday, December 23rdThursday, December 24thFriday, December 25thFull Week
Medical Questionaire:
Has your child had any recent surgery or illness?
YesNo
If yes please specify
Does your child take medication regularly?
YesNo
If yes please specify
Is your child current on his/her immunizations?
YesNo
May we give your child Tylenol or Benadryl if needed?
YesNo
Are there any medical concerns that your child's counselor should be aware of?
YesNo
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: