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Summer Camp Registration Form

Summer Camp Registration Form

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CAMP GAN ISRAEL REGISTRATION FORM
SUMMER 2017 - 5777

Please carefully complete this form, then click submit.
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NEW! Click here for the short form for returning campers

Campers Information

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

Contact Information

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

Father's Information

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

Mother's Information

English Name:  
Hebrew Name:  
Mother is:  
Home Phone:  
Cell 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:

Program Information

Program:  
Sessions Attending:  
Extra Care:  
Amount:  
Payment Method:  

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

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