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Fun Forever!

ב"ה

Register

$45 non-refundable registration fee per camper due with registration.
Family Information:
Family Name:*

Family Address:*

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

Phone Number:*
Area CodePhone Number
E-mail:*
Mother's Full Name:*
First NameLast Name
Mother's Hebrew Name:*
Mother's Phone Number:*
Area CodePhone Number
Father's Full Name:*
First NameLast Name
Father's Hebrew Name:*
Father's Phone Number:*
Area CodePhone Number
Emergency Contact Info:
Emergency Contact Name #1:*
First NameLast Name
Emergency Contact Phone Number #1:*
Area CodePhone Number
Relationship:*
Emergency Contact Name #2:*
First NameLast Name
Emergency Contact Phone Number #2:*
Area CodePhone Number
Relationship:*
Pediatrician Name:*
PrefixFirst NameLast Name
Pediatrician Phone Number:
Area CodePhone Number
Insurance Policy #:*
Camper Information:
Camper Name:*
Gender:*
MF
Date of Birth:*
MonthDayYear
Hebrew Birthday:*
School:*
Entering Grade:*
Health Notes:
Medication:
Allergies:
Health Problems or Disabilities:
Sessions Attending:
Please select all that apply:*
Week 1: June 27 – July 1, 2022Week 2: July 5 – July 8, 2022Week 3: July 11 - July 15, 2022Week 4: July 18 - July 22, 2022Week 5: July 25 - July 29, 2022Week 6: August 1 - August 4, 2022
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: $45
Total:
$0.00

I would like to pay today: Full amount$45.00 minimum $

Payment:

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I understand that the weekly fee of $185.00 is due each Monday. I agree to indemnify and hold harmless Gan Israel and its employees in case of injury, G‑d forbid. I gave my child permission to participate in all activities and for medical treatment to be administered in case of emergency.*
Should be Empty:

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