Printed from ChabadWinnipeg.org

Winter Camp Registration Form

Winter Camp Registration Form

בס"ד

Registration is currently closed for winter 2016/17.
Join us for family Chanukah fun
See you at camp this summer July 3rd-28th

--- 

CAMP GAN ISRAEL REGISTRATION FORM
WINTER 5776 (2015-16)

Please carefully complete this form, then click submit.
Secure This page uses 128 bit SSL encryption to keep your data secure.

NEW! Click here for the short form for returning campers

Campers Information

Family Name:  
English Name:  
Hebrew Name:  
   
Date of Birth:  
School:  
Grade:  

Contact Information

Child is in care of:  
Address:  
City:  
Postal Code:  

Father's Information

English Name:  
Hebrew Name:  
Father is:  
Home Phone:  
Cel Phone:  
Work Phone:  
E-Mail:  

Mother's Information

English Name:  
Hebrew Name:  
Mother is:  
Home Phone:  
Cel Phone:  
Work Phone:  
E-Mail:  

Emergency contact other than parent/guardian

Name:  
Relationship:  
Address:  
Phone:  

Medical Information

Family Medical Number:  
Camper's Personal Health I.D.:  
Camper's Doctor:  
Doctor's Tel #:  
Doctor's Address:  

Describe any medical information the camp should be aware of, such as allergies, medications, or any other concerns or special needs of your child:

Payment Information

Attending:  
Payment Method:  

If you are paying by Credit Card, please enter the following information:
Your Name as on Credit Card:  
Credit Card Number:  
Expiry Date:  
*Card Security Code  
Please enter any comments you have below:
 

Secure This page uses 128 bit SSL encryption to keep your data secure.