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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 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:*

M F
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: June 26 - 30, 2023 Week 2: July 3- 7, 2023 Week 3: July 10 - 14, 2023 Week 4: July 17 - 21, 2023 Week 5: July 24 - 28, 2023 Week 6: July 31 - August 3, 2023
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

We accept Visa, MasterCard, American Express, Discover
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.*
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