*Last Name
*First Name
Hebrew Name
*Gender Male Female
*Date of Birth
*Address
*City
*State
*Zip
Country
*Home Phone
*School
*Grade
Note
Physician Name
Physician Phone
Insurance
Insurance Number
Allergies
Medical Note
Title --Select Title-- Mr. Dr. Rabbi
First Name
Last Name
Work Phone
Cell Phone
Email
Title --Select Title-- Mrs. Ms. Miss
*Marital Status --Select -- Married Divorced Separated
Name Phone # Relation
*Emergency 1
Emergency 2
Tuition --Select-- M/W/F 5 Days a week
Extended Care --Select-- 3-4PM
Lunch --Select-- Hot Lunches
Total Amount:
These fees will not be charged now. Only a $25 non refundable registration fee will be charged today. To pay your balance online by credit card please visit www.campganisraelscv.com/tuition. If you will be paying by check or need a payment plan plese indicate it in the "note" field above.
Only registration fee ($25) will be charged at this time.
Registration Fee
*Card Type --Card Type-- Visa MC Amex
*Card Number
*Expiration Date --Month-- 01 02 03 04 05 06 07 08 09 10 11 12 --Year-- 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037
*Security Code
Use Information above
Name on Card
*Billing Address
*Billing Zip code
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Camp Gan Israel to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Camp Gan Israel personnel will try, but are not required, to communicate with me/us prior to such treatment.
I agree to the terms and conditions above
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