1. Child/ren’s Information How many children would you like to register for camp?* 1234 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 Dec 30Tuesday Dec 31Thursday Jan 2Friday Jan 3 Discount Applied 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 Dec 30Tuesday Dec 31Thursday Jan 2Friday Jan 3 Discount Applied 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 Dec 30Tuesday Dec 31Thursday Jan 2Friday Jan 3 Discount Applied 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 Dec 30Tuesday Dec 31Thursday Jan 2Friday Jan 3 Discount Applied 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 CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther 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? EmailFacebookInternet SearchAttended Previously FriendOther 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? (no aftercare on Fri) This is not confirmed until we notify you that there's enough interest AM (8-9:30)PM (3:30-5) 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 $75$275 Total $0.00 Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 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 I would like to receive news and updates by email Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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