Camper Information

*Last Name

*First Name

Hebrew Name

*Gender

*Date of Birth

*Address

*City

*State

*Zip

Country

*Home Phone

*School

*Grade

Note

Medical Information

Physician Name

Physician Phone

Insurance

Insurance Number

Allergies

Medical Note

Parent Information
Father

Title

First Name

Last Name

Work Phone

Cell Phone

Email

Mother

Title

First Name

Last Name

Work Phone

Cell Phone

Email

*Marital Status

Have there been adoptions or conversions in the family?

If yes, please explain

Emergency Information

Name Phone # Relation

*Emergency 1

Emergency 2

Enrollment Options / Tuition & Fees

Please choose enrollment options

Sessions
All Sessions (Save $50)





*Tuition

Extended Care

Lunch


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.

Payment Information

Only registration fee ($25) will be charged at this time.

Registration Fee

*Card Type

*Card Number

*Expiration Date

*Security Code

Use Information above

Name on Card

*Billing Address

*Billing Zip code

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