Camp Registration

Please fill out one form per child attending. If you would like to inquire about scholarships available please email us at [email protected]. This form is for locals only, if you are visiting and would like to sign up, please visit the camp registration page under the visitors tab.

Full Name*

First Name Last Name

Birth Date*

Month Day Year

Gender

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?

To register additional children, please fill out another form per child.

Full Name

Phone Number

Area Code Phone Number

Address

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

E-mail Primary email

Marital Status

MarriedSingleDivorcedSeparated

Religion

Jewish by birthJewish by conversionNot Jewish

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	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

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 Hour Minutes

Dates Attending*

Total

$0.00

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

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

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 Zalmen & Mrs. Geula Bernstein 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 $220 for the week or $60 per day, per camper to accompany registration and is non-refundable.
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.
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 $220 payment per camper (or $60 per day per camper) along with submission of this form.

Signature of Parent or Guardian

Date & Time

Month Day Year

at Hour Minutes

Summer Camp Registration

1. Child’s Information

Medical Information:

2. Parents Information

Mothers Info:

Fathers Info:

3. Emergency Information

4. Payment Information

5. Terms and Conditions