Registration Closes June 15

Camper 1
Camper 2
Camper 3
Campers Full Name
Campers Full Name
Campers Full Name
Hebrew Name
Hebrew Name
Hebrew Name
Date of Birth
Date of Birth
Date of Birth
Gender
Gender
Gender
School Attending
School Attending
School Attending
Entering Grade
Entering Grade
Entering Grade
General Information
Previous Camps Attended
How did you hear about Camp Gan Israel?
What goals would you like to see your child/ren accomplish during camp?
Briefly describe your child/ren's personality
Child/ren's favorite activities

Fees
$200 per week | $50 per day

Week 1: Monday, June 17 - Friday, June 21
9:00am - 3:00pm

Week 2: Monday, June 24 - Friday, June 28
9:00am - 3:00pm

10% off for addl siblings in family.
$25 off for each family referred

Parent's Information
Parent's Status Married Widowed Divorced Seperated
Home phone
Home Address
City/State/Zip
Father's full name
work phone
cell phone
Mother's full name
work phone
cell phone
Comments
Emergency Contact Information
Contact 1
Phone
Relationship to child
Contact 2
Phone
Relationship to child
Family Physician
Phone
Allergies
Are there any medical concerns that your child's counselor should be aware of?

Permission
I hereby give permission for my child to participate in all Camp Gan Israel activities and trips
I also hereby consent to the administration of Camp Gan Israel to take whatever medical
measures they deem necessary for my child, in the event of a medical emergency
I also authorize Camp Gan Israel to have and use photographs, slides and videos of the
person named on this application as needed for educational and public relations programs
Parent/Guardian Date

Payment Details
Last Name
First Name
Address
City
State
Zip
Total charge amount
Card Type
Card Number
Exp. Date
CVV code
Comments