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Camp Gan Israel registration

Camp Gan Israel registration

B"H

Gan Izzy Day Camp - Registration Form

Please complete the entire form

Campers info:

Last Name:

First Name:

Hebrew Name:

Date Of Birth: Gender:

Home Address:

City: State: Zip Code:

Home Phone:

E-mail:

School Sept. 2016: Entering Grade:

Fathers Name: Cell Phone:

Mothers Name: Cell Phone:

Emergency Contact Name: Cell Phone:

Doctor Name: Doctor Phone:

Specific Health Notes- if applicable

Session and fee schedule:

Week one: July 17- July 21 $125 

Week two: July 24 - July 28 $125 

 

Payment information

Credit Card Type:

Name on card:

Credit Card Number:

Ex. Date (Day/Month):

CVV-Code:

 

In case of emergency, I request Camp Gan Israel Day Camp to contact me. If the camp is unable to reach me, I hereby authorize the camp to call the physician indicated above and to follow his instructions. If camp cannot contact this physician, the camp may make whatever arrangements seem necessary. I hereby give permission for campers to attend all the field trips the camp will be taking. I understand that the camp will provide transportation, and that safety precautions will be taken at all times. Gan Israel will make every effort to insure the well-being of every camper. However, it will not be responsible for any injury or health impairment of any camper.

 

I Agree



Signature

Any comments or concerns:

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