Ages: Rising Kindergarten through 5th grade Sessions are only purchased from Monday - Friday, we are not able to divide weeks. Where did you hear about us? 1. Child/ren’s Information Number of children being registered Child 1 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions Early Bird Prices ($275 per Session - Multi Week $25 discount per week.) Session are only Mon-Fri ONLY CHOOSE ONE* 1 Week $2752 Weeks $5503 Weeks $8254 Weeks $10005 Weeks $1,250 Choose which sessions Ages: Rising K-5 Week 1 June 23 - June 27Week 2 June 30 - July 4Week 3 July 7 - July 11Week 4 July 14 - July 18Week 5 July 21 - July 25 Lunch If sending two children or less - $25 a week per child. If sending at least three children - $15 a week per child. Week 1 $25 if sending two children or lessWeek 2 $25 if sending two children or lessWeek 3 $25 if sending two children or lessWeek 4 $25 if sending two children or lessWeek 5 $25 if sending two children or lessWeek 1 $15 if sending at least 3 childrenWeek 2 $15 if sending at least 3 childrenWeek 3 $15 if sending at least 3 childrenWeek 4 $15 if sending at least 3 childrenWeek 5 $15 if sending at least 3 children Early Care and After Care $40 a week for each. Week 1 Early CareWeek 2 Early Care - No Early Care July 4Week 3 Early CareWeek 4 Early CareWeek 5 Early CareWeek 1 After CareWeek 2 After Care - No After Care July 4Week 3 After CareWeek 4 After CareWeek 5 After Care Medical Information Child 1: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - As a swimmer, my child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo T-Shirt Size (Tshirts free until March 15)* Extra T-Shirt option - $12. only available until April 1 T4XSYouth SmallYouth MediumYouth LargeAdult SmallExtra T-shirt Are there any social or other challenges we should be aware of? Child 2 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($275 per Session - Multi Week $25 discount.) Session are only Mon-Fri ONLY CHOOSE ONE 1 Week $2752 Weeks - $5503 Weeks - $8254 Weeks $10005 Weeks $1,250 Choose which sessions Week 1 June 23 - June 27Week 2 June 30 - July 4Week 3 July 7 - July 11Week 4 July 14 - July 18Week 5 July 21 - July 25 Lunch : If sending two children or less - $25 a week per child. If sending at least three children - $15 a week per child. Week 1 $25 if sending two children or lessWeek 2 $25 if sending two children or lessWeek 3 $25 if sending two children or lessWeek 4 $25 if sending two children or lessWeek 5 $25 if sending two children or lessWeek 1 $15 if sending at least 3 childrenWeek 2 $15 if sending at least 3 childrenWeek 3 $15 if sending at least 3 childrenWeek 4 $15 if sending at least 3 childrenWeek 5 $15 if sending at least 3 children Early Care and After Care $40 a week for each. Week 1 Early CareWeek 2 Early CareWeek 3 Early CareWeek 4 Early CareWeek 5 Early CareWeek 6 Early CareWeek 1 After CareWeek 2 After CareWeek 3 After CareWeek 4 After CareWeek 5 After CareWeek 6 After Care Medical Information Child 2: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? T-Shirt Size * Extra T-Shirt option - $12 only available until April 1 T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $12 T-Shirt Size * Extra T-Shirt option - $12 only available until April 1 T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $12 Child 3 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Lunch : If sending two children or less - $25 a week per child. If sending at least three children - $15 a week per child.* Week 1 $15 if sending at least 3 childrenWeek 2 $15 if sending at least 3 childrenWeek 3 $15 if sending at least 3 childrenWeek 4 $15 if sending at least 3 childrenWeek 5 $15 if sending at least 3 children Sessions ($275 per Session - Multi Week $25 discount.) Session are only Mon-Fri 1 Week $2752 Weeks $5503 Weeks $8254 Weeks $10005 Weeks $1250 Choose which sessions Week 1 June 23 - June 27Week 2 June 30 - July 4Week 3 July 7 - July 11Week 4 July 14 - July 18Week 5 July 21 - July 25 Early Care and After Care $40 a week for each. Week 1 Early CareWeek 2 Early CareWeek 3 Early CareWeek 4 Early CareWeek 5 Early CareWeek 1 After CareWeek 2 After CareWeek 3 After CareWeek 4 After CareWeek 5 After Care Medical Information Child 3: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? T-Shirt Size * Extra T-Shirt option only available until April 1 T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $12 Child 4 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($275 per Session - Multi Week $25 discount.) Session are only Mon-Fri 1 Week $2752 Weeks $5503 Weeks $8254 Weeks $10005 Weeks $1,250 Choose which sessions Week 1 June 23 - June 27Week 2 June 30 - July 4Week 3 July 7 - July 11Week 4 July 14 - July 18Week 5 July 21 - July 25 Lunch : If sending two children or less - $25 a week per child. If sending at least three children - $15 a week per child. Week 1 $15 if sending at least 3 childrenWeek 2 $15 if sending at least 3 childrenWeek 3 $15 if sending at least 3 childrenWeek 4 $15 if sending at least 3 childrenWeek 5 $15 if sending at least 3 children Early Care and After Care $40 a week for each. Week 1 Early CareWeek 2 Early CareWeek 3 Early CareWeek 4 Early CareWeek 5 Early CareWeek 1 After CareWeek 2 After CareWeek 3 After CareWeek 4 After CareWeek 5 After Care Medical Information Child 4: Pediatrician First Name Last Name Phone Number Area Code Phone Number Insurance My child is permitted to be given Children's Tylenol, Motrin or similar should the need arise YesNo Is your child allergic to any medications? If yes, please explain Is your child allergic to any foods? If yes, please explain Is your child up to date on all immunizations? YesNo Does your child have a medical, developmental or emotional condition that camp should be aware of? If yes, please explain Please answer as accurately as possible - My child is: Beginner - Not comfortable in water deeper than 3 ft.Intermediate - Comfortable in water deeper than 3 ft.Advanced - An excellent swimmer. Is your child adopted? YesNo Are there any social or other challenges we should be aware of? T-Shirt Size * Extra T-Shirt option only available until April 1 T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $12 If you have additional children, please contact us. 2. Parents Information Mothers Info: Full Name Phone Number Area Code Phone Number Address Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country E-mail Primary email Marital Status MarriedSingleDivorcedSeparated Fathers Info: Full Name Phone Number Area Code Phone Number Address Leave blank if same as above Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country E-mail Primary email Marital Status MarriedSingleDivorcedSeparated Child may be picked up from camp by: Name and Relationship I would like to receive news and updates by email 3. Emergency Information Emergency Contact First Name Last Name Phone Number Area Code Phone Number Relationship Agreement I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid.I give Gan Israel permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit. I hereby give consent to the administration of Camp Gan Israel to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I understand that, when possible, every effort will be made to contact parent/guardian or emergency contact before Camp Gan Israel will undertake such a decision. Signature of Parent or Guardian Date & Time Month Day Year 4. Payment InformationA $50 non-refundable registration fee per child applies as part of this registration. * $50 Registration Fee Total $0.00 I would like to pay today:Full amount$50.00 minimum$ If you would like to make a payment plan, please detail when you would like to be charged and preferred payment option. Venmo, Paypal, Check and Credit card all accepted. Payment* Will only charge the option you chose above Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2025202620272028202920302031203220332034 Expiration YearBilling Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country General comments 5. Terms and Conditions PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Camp Gan Israel (CGI) both on and off site, trips, transportation to and from trips etc., unless I advise you otherwise in writing. Limited Guardianship Approval: I hereby consent that CGI's directors - Rabbi Zalman & Mrs. Libby Groner be granted limited guardianship capabilities with regards to signing waivers on behalf of my child / children for trips specified in this year's camp schedule. (I do understand that I may still be asked to fill out waivers, as not all locations accept this consent) PAYMENT AND CANCELLATION: Payment terms are a $50.00 non-refundable deposit per camper to accompany registration. The balance is due by June 9, and is non-refundable after that date. DISMISSAL OF CAMPER: Parent fully understands and agrees that the Camp reserves the right to dismiss, in its sole discretion, any Camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the Camp or fellow campers or who violates camp rules and regulations. In the event of dismissal, tuition will be refunded on a prorated basis less the $50.00 registration deposit. INDEMNIFY & HOLD HARMLESS: I further release and agree to indemnify and hold harmless Camp Gan Israel (CGI) and its officers, servants or assignees from any liability concerning our child’s involvement in CGI and further agree that the use of any premises during the CGI camp day is made at the risk of the registrant. I have read and agree to all of the terms and conditions in this Application Form. I am including a non-refundable $50 registration deposit per camper along with submission of this form. I further agree to remit the full tuition and any other fees by June 9 as per the agreed timeline of my choice on this form. Signature of Parent or Guardian Date Month Day Year Should be Empty: Submit This page uses TLS encryption to keep your data secure.
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