| Camper/Parent Information | ||||||
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Name
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First
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Middle | Last | |||
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Address
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Street
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City |
State
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Zip
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Date of Birth
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Contact Info
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Phone
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Email
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Schools
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School
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Hebrew School | Entering Grade:
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Child's Mother
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Mother's Name | Work Phone | Cell
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Child's Father
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Father's Name
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Work Phone | Cell
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Emergency Contact Info
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Name
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Phone | Relationship | |||
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Pediatrician
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Name
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Phone | ||||
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| Summer Camp Fees & Dates: | |||||||||
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Fees
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$40 a day $180 a week | ||||||||
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Days Attending
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Monday Tuesday Wednesday Thursday Friday | ||||||||
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Extended Care |
$10 a day | ||||||||
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Days Needed
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Monday Tuesday Wednesday Thursday Friday | ||||||||
| Payment and agreements | |||||||||
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•
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All forms must be completed and submitted for the Winter Camp in order to secure a place for your child. | ||||||||
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•
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Credit Card Number Exp CVV
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I have read the camp brochure and application form and agree to the terms stated. I give my child permission to attend all trips, and receive medical care in the case of emergency.
Also, I give Gan Israel permission to photograph and videotape my children and use the photos and videos for whatever the camp sees fit. |
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Print name of parent filling out form |
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