Register - ChabadColorado.com

Family Address:*

Phone Number:*

Area Code Phone Number
E-mail:*
Mother's Full Name:*

First Name Last Name
Mother's Hebrew Name:*
Mother's Phone Number:*

Area Code Phone Number
Father's Full Name:*

First Name Last Name
Father's Hebrew Name:*
Father's Phone Number:*

Area Code Phone Number
Emergency Contact Info:
Emergency Contact Name #1:*

First Name Last Name
Emergency Contact Phone Number #1:*

Area Code Phone Number
Relationship:*
Emergency Contact Name #2:*

First Name Last Name
Emergency Contact Phone Number #2:*

Area Code Phone Number
Relationship:*
Pediatrician Name:*

Prefix First Name Last Name
Pediatrician Phone Number:

Area Code Phone Number
Insurance Policy #:*
Camper Information:
Camper Name:*
Gender:*

MF
Date of Birth:*

Month Day Year
Hebrew Birthday:*
School:*
Entering Grade:*
Health Notes:
Medication:
Allergies:
Health Problems or Disabilities:
Sessions Attending:
Please select all that apply:*

Week 1: July 1 - 5, 2024Week 2: July 8 - 12, 2024Week 3: July 15 - 19, 2024Week 4: July 22 - 26, 2024Week 5: July 29 - August 2, 2024Week 6: August 5 - 8, 2024
Payment Information:

IMPORTANT: All forms must be completed and submitted before your child begins camp.
I authorize Camp Gan Israel to charge my card non-refundable registration fees in the amount of:*

Registration Fee: $50

Payment:

Credit Card

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

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I understand that the weekly fee of $215.00 is due each Monday. I agree to indemnify and hold harmless Gan Israel and its employees in case of injury, G‑d forbid. I give my child permission to participate in all activities and for medical treatment to be administered in case of emergency.*
Total

$0.00
Should be Empty:

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Family Information: