Camp Registration

Camper Information

*First Name
*Last Name
Hebrew Name
*Gender
*Date of Birth
*Address
*City
*State
*Zip

*Home Phone
*School
*Grade

Parent Information

Father


First Name
Last Name
Work Phone
Cell Phone
Email

Mother


First Name
Last Name
Work Phone
Cell Phone
Email

Marital Status

Have there been adoptions or conversions in the family?
If yes, please explain

Medical Information

Physician Name
Physician Phone
Insurance
Insurance Number
Allergies
Medical Note

Emergency Information

	Name	Phone #	Relation
*Emergency 1

Enrollment Options / Tuition & Fees

Click here for tuition fee details

Sessions

All Weeks

Week 1: July 1 - July 5

Week 2: July 8 - July 12

Week 3: July 15 - July 19

Week 4: July 22 - July 26

*Tuition
After Care / Late Pickup
Total Amount:

These tuition fees will be charged upon acceptance of your child on or after June 1.
Registration fee $75 will be charged when submitting this form.

Payment Information

The tuition fees (on previous page) will be charged upon acceptance of your child on or after June 1. Registration fee only is being charged at this time.
Registration Fee
*Payment Type
*Card Number
*Expiration Date
*Security Code
	Use my Contact Information
*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. It is also understood that Camp Gan Israel can take photos and videos of your child and display them on the camp website and otherwise publicize them. I reviewed the tuition details and refund policy on the Pricing page.

I agree to the terms and conditions above

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