Camp Registration Form

Primary Contact

First Name *

Last Name *

Phone Number *

Email *

Street Address *

City *

Postal Code *

State/Province *

Relationship to child *

Activity Subject

Secondary Contact

First Name *

Last Name *

Gender

Phone Number *

Email *

Relationship to child *

Share address

Same Address?

Street Address *

City *

Postal Code *

State/Province *

Relationship to Father Relationship Type(s)

How many kids do you want to apply for? *

Child 1

First Name *

Last Name *

Gender *

Birth Date *

Month

Day

Year

Grade in the coming year *

	Before Mar 19th Early Bird Rate	After Mar 19th Main Rate	After Jun 19th Late Rate
Per week	$270	$290	$300
Full Summer	$1500 ($250/week)	$1620 ($270/week)	$1740 ($290/week)

Weeks of camp the child will attend *

Does the child need Early/late stay?

Select Weeks for Early stay

Extra $50/week

Select Weeks for Late stay

Extra $70/week

School attending *

Does your child have an IEP? *

Yes

We're here to make your child's time special. Let us know anything we should be aware of, whether it's sensory preferences, ADHD, a sensitivity, or anything else.

With your Camp Gan Israel registration, your child will receive a free CGI T-shirt. What size would be best? *

Medical History

Does the child have a chronic illness? *

Yes

receiving medication on a regular basis? *

Yes

Does the child have allergies? *

Yes

Chronic illness detailes *

Medication details *

Allergy details *

Please list any information that may directly affect the safe care or medical treatment of your child

Camp weekly fee $

Early stay per week $

Late stay per week $

Relationship Type(s) 2

Authorization for Emergency Medical Care

Doctor’s Full Name *

Office Phone Number *

Preferred Hospital *

In the event my child becomes ill or is injured at school or while under the supervision of the school, I hereby authorize any employee or representative of Gan Gani Preschool to obtain medical aid for my child. I have been advised by the school that it will exercise such authorization when I cannot be contacted in time. I acknowledge that charges for such medical care will be my responsibility and not that of Gan Gani Preschool.

Signature of Parent *

Date *

Month

Day

Year

Registration fee $

$75/child

Security Fee $

$55/child

Authorization_1 *

I hereby give permission for my child to participate in all camp activities. In addition, I give Camp Gan Israel permission (a) to transport campers in connection with activities (b) to render necessary first aid or to arrange care by medical personnel, if deemed necessary; (c) to use photographs and videos and names of campers in printed material and websites associated with CGI; (d) I indemnify and hold harmless Camp Gan Israel from any liability or claim for any loss, injury, damage or expense resulting or arising from my child's participation in camp activities. In addition, I acknowledge that the camp administration reserves the right to reconsider the enrollment of any camper if we feel the child's needs or level of functioning or behavior cannot be accommodated, or if the child's conduct limits his or her ability to participate in, or to benefit fully from, the program and activities at CGI. In addition, I acknowledge that I have read and accept the financial obligations and the refund policy as stated in the application form.

Yes *

Child 1 - Full camp discount $

Child 2 - Full camp discount $

Child 3 - Full camp discount $

Child 4 - Full camp discount $

Discount Code

Discount Amount

Payment Options *

In full

3 monthly payments

5 monthly payments

Interval of Installments

Contribution Source

Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of

Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of

Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of

Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of

Camp Registration

Chabad Center for Jewish Life & Learning