1. Child/ren’s Information Number of children being registered Child 1 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($300 per session) Week 1Week 2 Medical Information Child 1: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? Child 2 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($200 per session) Week 1Week 2 Medical Information Child 2: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? Child 3 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($175 per session) Week 1Week 2 Medical Information Child 3: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? Child 4 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions (175 per session) Week 1Week 2 Medical Information Child 4: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? If you have additional children, please contact us. 2. Parents Information Mothers Info: Full Name Phone Number Area Code Phone Number Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country E-mail Primary email Marital Status MarriedSingleDivorcedSeparated Religion Jewish by birthJewish by conversionNot Jewish Fathers Info: Full Name Phone Number Area Code Phone Number Address Leave blank if same as above Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country E-mail Primary email Marital Status MarriedSingleDivorcedSeparated Religion Jewish by birthJewish by conversionNot Jewish Child may be picked up from camp by: Name and Relationship I would like to receive news and updates by email 3. Emergency Information Emergency Contact First Name Last Name Phone Number Area Code Phone Number Relationship I hereby give consent to the administration of Camp Gan Israel to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I understand that, when possible, every effort will be made to contact parent/guardian or emergency contact before Camp Gan Israel will undertake such a decision. Signature of Parent or Guardian Date & Time Month Day Year at 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM 4. Payment Information Total $0.00 I would like to pay today:Full amount20% minimum: $0.00 $ Scholarship, please call Rabbi Menachem for details $0 Agreement* I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid. 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. General comments 5. Terms and Conditions PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Camp Gan Israel (CGI) both on and off site, trips, transportation to and from trips etc., unless I advise you otherwise in writing. Limited Guardianship Approval: I hereby consent that CGI's directors - Rabbi Menachem Caytak & Mrs.Chana Caytak be granted limited guardianship capabilities with regards to signing waivers on behalf of my child / children for trips specified in this year's camp schedule. (I do understand that I may still be asked to fill out waivers, as not all locations accept this consent) PAYMENT AND CANCELLATION: Payment terms are a $50.00 non-refundable deposit per camper to accompany registration. The balance is due by June 9, and is non-refundable after that date. DISMISSAL OF CAMPER: Parent fully understands and agrees that the Camp reserves the right to dismiss, in its sole discretion, any Camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the Camp or fellow campers or who violates camp rules and regulations. In the event of dismissal, tuition will be refunded on a prorated basis less the $50.00 registration deposit. IMAGES, ETC.: Permission is hereby given to use in promoting the Camp and in other ventures directly relating to the Camp (i) digital, photographic and video images or likenesses of camper; audio of camper; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by camper or originating from Camp or from a Camp-related activity. INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless Camp Gan Israel (CGI) and its officers, servants or assignees from any liability concerning our child’s involvement in CGI and further agree that the use of any premises during the CGI camp day is made at the risk of the registrant. I have read and agree to all of the terms and conditions in this Application Form. I am including a non-refundable $50 registration deposit per camper along with submission of this form. I further agree to remit the full tuition and any other fees by June 9 as per the agreed timeline of my choice on this form. Signature of Parent or Guardian Date & Time Month Day Year at 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM Payment Credit Card eCheck Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Expiration Year Bank Name Routing Number Account Number Checking Savings Business Account Type Billing Address Street Address City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Should be Empty: Submit This page uses TLS encryption to keep your data secure.
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