CGI Winter Camp 
 
Registration and Payment Form

Please complete this registration form. 
Please note:  We need this form filled out COMPLETELY  and SIGNED before any child can be fully registered.

PARENT INFORMATION

  Mother's Name   
  Address City/State/Zip
  Cell Phone Home Phone
  Work Phone Email Address
  Father's Name Same address
  Address City/State/Zip
  Cell Phone Home Phone
  Work Phone Email Address


 

1. Camper's Name: [Last, First] 

  Gender & DOB:   

M  F         
                  

  Grade [Fall 2013]:   School Attending [Fall 2013]:
  Select all that apply

Days: 

M- 12/23 T-12/24 W-12/25 Th-12/26 F-12/27
M- 12/30 T - 12/31 W - 1/1 Th- 1/2 F- 1/3

Extended Care:
(No extended care on Fridays)

AM (8:00 - 9:00) PM1 (3:30 - 4:30) PM2 (4:30 - 5:30)


 
  MEDICAL HISTORY
  In the past six months, has your child had any serious illnesses?
     No Yes.  If yes, please list:
  Does your child have any allergies?
    No Yes.  If yes, please describe:


 

  **If you are only registering one camper, please skip to "Transportation Information"**

2. Camper's Name: [Last, First]

  Gender & DOB:    M  F           
                      
  Grade [Fall 2013]:   School Attending [Fall 2013]:
  Select all that apply

Days:
 

M- 12/23 T-12/24 W-12/25 Th-12/26 F-12/27
M- 12/30 T - 12/31 W - 1/1 Th- 1/2 F- 1/3

 Extended Care:
(No extended care on Fridays)

AM (8:00 - 9:00) PM1 (3:30 - 4:30) PM2 (4:30 - 5:30)
 

 
  MEDICAL HISTORY
  In the past six months, has your child had any serious illnesses?
     No Yes.  If yes, please list:
  Does your child have any allergies?
    No Yes.  If yes, please describe:


 

3. Camper's Name:[Last, First] 

  Gender & DOB:    M  F             
                      
  Grade [Fall 2013]:   School Attending  [Fall 2013]:
  Select all that apply

  Days:

M- 12/23 T-12/24 W-12/25 Th-12/26 F-12/27
M- 12/30 T - 12/31 W - 1/1 Th- 1/2 F- 1/3

Extended Care:
(No extended care on Fridays)

AM (8:00 - 9:00) PM1 (3:30 - 4:30) PM2 (4:30 - 5:30)
  MEDICAL HISTORY
  In the past six months, has your child had any serious illnesses?
     No Yes.  If yes, please list:
  Does your child have any allergies?
    No Yes.  If yes, please describe:


 

TRANSPORTATION INFORMATION
  Please let us know who, other than yourself, has permission to pick up your child from camp: [Please note: Your child will not be released to anyone not on this list]:
  I am interested in car pooling with other parents: Yes No

 

EMERGENCY CONTACT INFORMATION

Please list at least one emergency contact other than the child's parents.
1. Emergency Contact Name [other than parents]
  Relationship to Child
  Address City/State/Zip
  Home Phone Other Phone
2. Emergency Contact Name [other than parents]
  Relationship to Child
  Address City/State/Zip
  Home Phone Other Phone
 

Physician Contact Information
  Name of Child's Physician or Medical Facility  
  Phone Address

 

 

 MAKE A PAYMENT
Camp Tuition Rates: 
Full 10 Days: $475   
Weekly Rate: $245 
Daily Rate: $53 
5% Sibling Discount

  Pay Full Winter Camp Tuition 
  Pay Half of My Total Today and Half on December 16th
     
  Name on Card: Payment Amount:
  CC Type:   CC Number:
  Exp. Date:   CCV#: (on back of card)

 

 

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.

I understand that my deposit is non-refundable and that full payment is due by December 16th, at which time the balance of tuition becomes non-refundable, and that refunds will not be made for incomplete attendance.  In addition, I understand that sending in a deposit does not guarantee me a spot in camp, and that acceptance into Camp Gan Israel's Winter Camp is at the discretion of the camp.

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:


 

 

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If needed, please call our office 703.426.1980 x4, for a
paper copy of the registration form.