Registration App (junior Division) V4

CAMP GAN ISRAEL WINTER DAY CAMP ● 821 Hawkins Ave, Lake Grove NY 11755 ● 631-585-0521 ● Fax: 631-585-0570 ● www.CampGanIsraelSB.com ● [email protected] “A winter experience your child will never forget!”

CAMPER INFORMATION CHILD 1

CHILD 2

CHILD 3

Last Name: First Name: Full Hebrew name: Date of Birth: Male/Female: School Attending: Grade:

PARENT INFORMATION Mother’s Name

Mother’s Full Hebrew

Name:___________________________________ Is the natural mother of the child Jewish? Yes  No  Father’s Name: Father’s Full Hebrew Name: ___________________________________________ Home Phone: (_____) ______-________ Mothers Mobile: (_____) ______-________ Fathers Mobile: (_____) ______________ Address____________________________ City: ________ State: ____ Zip:__________ Email:______________________________

EMERGENCY CONTACT INFORMATION

(when either parent is not reachable)

Emergency Contact Name:______________________________ Relationship to child:_______________________________ Home Phone:(_____) ______-_______ Work Phone:(_____) ______-_______ Mobile Phone:(_____) ______-_______ Physician or Medical Facility Name_______________________________________________ Phone: ____________________ Is there anything special that you would like us to know about your child (allergies, specific health notes etc.)? ______________________________________________________________________________________________________________________________________________________________________________________

Please enclose a copy of your child’s insurance card with this form.

CAMP TUITION Please select the program of your choice:  Full week- $225  Friday (12/25) only- $50

(Early bird- Register before Nov 30, 2009 for 10% off)

Sponsor a Camper- Yes! I would like to enable another child to enjoy winter camp at Camp Gan Israel. I am enclosing:  $225 for full week  $50 for Friday only  $__________ towards tuition for another camper.  I’ve enclosed a check made payable to: Camp Gan Israel at Stony Brook, in the amount of $_______. Check date: ___/___/_____ Check number: _________ Check amount: $____________ Cash amount: $__________  Please charge $________ towards camp tuition.  Mastercard  Visa  American Express (card #)____________________________________Exp Date: ____/____ Signature : __________________________________________ Date: ___/___/_____ Please note that any payment arrangement must be made prior to handing in this form and must be approved by the Camp Director.

PARENTAL CONSENT  You can include my child’s photo to be used on the website, video & any other Camp Gan Israel related publications. I hereby permit my child to participate in all activities at Camp Gan Israel – on site, off-site and trips. I release Camp Gan Israel and individuals from liability in case of accident during activities related to camp, as long as normal safety procedures have been taken. I am enclosing the non refundable camp fee for each child.

Print Name:______________________________________ Relation to Child:____________________________________ _________________________________________________ Parents or Legal Guardian’s Signature

Date_____/______/__________