Camp Registration

Camper Information

*First Name
*Last Name
Hebrew Name
*Gender
*Date of Birth
*Address
*City
*State
*Zip
Country
*Home Phone
*School
*Grade
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

Medical Information

Physician Name
Physician Phone
Insurance
Insurance Number
Allergies
Medical Note

Emergency Information

	Name	Phone #	Relation
*Emergency 1
Emergency 2

Enrollment Options / Tuition & Fees

Sessions

All Sessions (Save $)

Week 1: June 30 - July 4

Week 2: July 7 - July 11

Week 3: July 14 - July 18

Week 4: July 21 - July 25

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

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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