Gan Izzy Winter Camp Registration Form 2012

The activities brochure is available HERE 

Last Name           

Mother's Name      

Father's Name      

Address               

City, State ZIP      

Home Phone        

Father's cell          

Mother's cell         

Father's Work        

Mother's Work       

E-mail Address  


Child's name            Grade

Child's name            Grade

Child's name            Grade

Days Attending: (Check all that apply)
Dec. 24   Dec. 25   Dec. 26   Dec. 27   Dec. 28

DayCare: (No PM DayCare Friday Dec. 28th)
AM (8:00-9:00)    PM1 (3:30-4:30)    PM2 (4:30-5:30)

Medical Information:

Family Physician Name    Phone   
Insurance Policy            Number   

If your child is taking medication, has allergies or has another medical condition we
should be aware of, please enter the information here:


Emergency Contact Information:
Please list two emergency contacts other than a parent

Name Phone Number Relationship to child

 

Name Phone Number Relationship to child


 Payment:

Cost: $53.00 per day/ $230 per week (includes all trips, Lunch, snacks and activities). 
Daycare $5.00 per hour (No aftercare Friday Dec. 28)

Total cost:  

Please complete the following section for credit card payments:
 

VISA      

    MasterCard     American Express  
   Card Number:   Exp: mm/yyyy /
     
 

Card ID Number:  

 Where's my Card ID Number?

  

REGISTRATION POLICIES AND PARENTAL CONSENT

 

I hereby permit Camp Gan Israel to transport my child(ren) on camp provided transportation and to obtain emergency medical care as the situation mandates.

It is my responsibility to dress my child(ren) appropriately every morning before camp with regards to that day's activities.

I am giving my permission for my child(ren) to participate in any field trips and any other activity that is scheduled on the CGI Winter Camp calendar. 

I allow Camp Gan Israel to photograph and/or videotape my child(ren) and to use these images for all promotional purposes.

The parent who signs this registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fees.

  By typing my name and the date below, I certify that the information on this application is true and correct and that I have read, and approve, the policies listed above.
  Your Name: Date: 


Additional Comments: