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 ($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 $1,2506 Weeks $1,500 Choose which sessions Ages: Rising K-5 Week 1 June 17 - June 21Week 2 June 24 - June 28Week 3 July 1 - July 5Week 4 July 8 - July 12Week 5 July 15 - July 19Week 6 July 22 - July 26 Lunch If sending two children or less - $20 a week per child. If sending at least three children - $15 a week per child. Week 1 $20 if sending two children or lessWeek 2 $20 if sending two children or lessWeek 3 $20 if sending two children or lessWeek 4 $20 if sending two children or lessWeek 5 $20 if sending two children or lessWeek 6 $20 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 childrenWeek 6 $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 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 April 1)* Extra T-Shirt option only available until March 20th 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 $1,2506 Weeks $1,500 Choose which sessions Week 1 June 17 - June 21Week 2 June 24 - June 28Week 3 July 1 - July 5Week 4 July 8 - July 12Week 5 July 15 - July 19Week 6 July 22 - July 26 Lunch : If sending two children or less - $20 a week per child. If sending at least three children - $15 a week per child. Week 1 $20 if sending two children or lessWeek 2 $20 if sending two children or lessWeek 3 $20 if sending two children or lessWeek 4 $20 if sending two children or lessWeek 5 $20 if sending two children or lessWeek 6 $20 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 childrenWeek 6 $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 only available until March 20th T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $15 Child 3 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 $12506 Weeks $1,500 Choose which sessions Week 1 June 17 - June 21Week 2 June 24 - June 28Week 3 July 1 - July 5Week 4 July 8 - July 12Week 5 July 15 - July 19Week 6 July 22 - July 26 Lunch : If sending two children or less - $20 a week per child. If sending at least three children - $15 a week per child. Week 1 $20 if sending two children or lessWeek 2 $20 if sending two children or lessWeek 3 $20 if sending two children or lessWeek 4 $20 if sending two children or lessWeek 5 $20 if sending two children or lessWeek 6 $20 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 childrenWeek 6 $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 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 March 20th T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $15 Child 4 Full Name First Name Last Name Birth Date Month Day Year Gender Grade entering Sessions ($250 per Session - Multi Week $25 discount.) Session are only Mon-Fri 1 Week $2502 Weeks $5003 Weeks $7504 Weeks $9005 Weeks $1,1256 Weeks $1,350 Choose which sessions Week 1 June 17 - June 21Week 2 June 24 - June 28Week 3 July 1 - July 5Week 4 July 8 - July 12Week 5 July 15 - July 19Week 6 July 22 - July 26 Lunch : If sending two children or less - $20 a week per child. If sending at least three children - $15 a week per child. Week 1 $20 if sending two children or lessWeek 2 $20 if sending two children or lessWeek 3 $20 if sending two children or lessWeek 4 $20 if sending two children or lessWeek 5 $20 if sending two children or lessWeek 6 $20 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 childrenWeek 6 $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 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 March 20th T4XSYouth SmallYouth MediumYouth LargeAdult SmallLong Sleeves $3Extra Tshirt $15 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 Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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 Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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 Information A $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 your card to be charged. 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 Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Expiration Year Billing Address Street Address City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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.