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Mid-Winter Camp Registration Feb 2024

This form is currently closed.

1. Child/ren’s Information
How many children would you like to register for camp?*
CHILD 1*

First Name Last Name
Hebrew Name
Gender*

MaleFemale
Birth Date*

Month Day Year
Born after sunset This is to help determine the Jewish birthdate

YesNo
School Attending*
Grade*
Days*

Monday Feb 19Tuesday Feb 20I'm interested in camp Wed 2/21 as well if the minimum is met
CHILD 2

First Name Last Name
Hebrew Name
Gender

MaleFemale
Birth Date

Month Day Year
Born after sunset This is to help determine the Jewish birthdate

YesNo
School Attending
Grade
Days*

Monday Feb 19Tuesday Feb 20I'm interested in camp Wed 2/21 as well if the minimum is met
CHILD 3

First Name Last Name
Hebrew Name
Gender

MaleFemale
Birth Date

Month Day Year
Born after sunset This is to help determine the Jewish birthdate

YesNo
School Attending
Grade
Days*

Monday Feb 19Tuesday Feb 20I'm interested in camp Wed 2/21 as well if the minimum is met
CHILD 4

First Name Last Name
Hebrew Name
Gender

MaleFemale
Birth Date

Month Day Year
Born after sunset This is to help determine the Jewish birthdate

YesNo
School Attending
Grade
Days*

Monday Feb 19Tuesday Feb 20I'm interested in camp Wed 2/21 as well if the minimum is met
If you have additional children please contact us.
2. Parents information
Parents' Status*

MarriedDivorcedSeparatedWidowedSingle
Home Phone Number

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

MOTHER'S NAME

First Name Last Name
E-mail* Primary email
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Occupation
FATHER'S NAME

First Name Last Name
E-mail
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Occupation
Synagogue Affiliation
How did you hear of us?
Who can we thank for referring you?
Is the natural mother of the child/ren Jewish?*

YesNo
Is the natural father of the child/ren Jewish?*

YesNo
Were there any conversions or adoptions in the family? *

YesNo
If yes, please explain
Are you interested in early care or after care? This is not confirmed until we notify you that there's enough interest

AM (8:30-10:00)PM (4:00-5:00)
3. Medical & Emergency Information
Are your child(ren)'s immunizations up to date? (CGI requires all campers to be up to date with immunizations unless they have a medical exemption)*

YesNo
Please specify if your child takes any prescription medication Please specify name of medication, dosage, time of dosage and any special instructions
Please specify if your child has any known allergies
Are there any medical or behavioral concerns that your child's counselor/s should be aware of?
Emergency Contact*
Phone Number*

Area Code Phone Number
Relationship*
Pediatrician
Phone Number

Area Code Phone Number
In the event that I am not able to pick up my child, he/she may be released only to the following people:
4. Payment Information
Yes! I would like to sponsor another camper to enjoy Camp Gan Israel $70 covers 1 day of camp, $250 covers full week

$70$250
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Agreement*

I am signing up my child for camp. I give my child permission to participate in all activities, attend all trips on camp-provided transportation and receive medical care in the case of emergency, G-d forbid. I release Camp Gan Israel at The Shul and individuals from liability in case of accident during activities related to Camp Gan Israel at The Shul, as long as normal safety procedures have been taken. I give Gan Israel permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit. The parent/guardian who signs the registration form represents that he/she has full authority to do so and will be responsible for payment of the camp tuition.
Parent/Guardian's Signature*
Comments
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Camp Gan Israel

at The Shul

1. Child/ren’s Information

2. Parents information

3. Medical & Emergency Information

4. Payment Information

Camp Address