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


*First Name
*Last Name
Work Phone
*Cell Phone
*Email

Mother


*First Name
*Last Name
Work Phone
*Cell Phone
*Email

Medical Information

Physician Name
Physician Phone
Insurance
Insurance Number
*Allergies
Medical Note

Emergency Information

	Name	Phone #	Relation
*Emergency 1
Emergency 2
Emergency 3

Enrollment Options / Tuition & Fees

Please choose enrollment options

Sessions

Camp Gan Izzy 2024: 6/24/24 - 6/28/24

*Tuition
Total Amount:

These fees will only be charged upon acceptance of your child

Payment Information

Only registration fee will be charged at this time.
Registration Fee
*Payment 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.As well sending your child to Camp Gan Izzy parents/guardians agree to indemnify and hold harmless Camp Gan Izzy and its officers, employees or assigns from any liability concerning the contraction or spread of Covid-19 or other infectious diseases. While we will take precautions to prevent the spread of Covid - 19, parents and guardians register their child for camp at their own risk and agree to not hold Camp Gan Izzy or Chabad Longmont liable in the event that their child contracts Covid - 19 or a related illness.

I agree to the terms and conditions above

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