Forms - Chabad of Southlake

Camper Information
Full Name*
First NameLast Name
Full Name*
First NameLast Name
Full Name*
First NameLast Name
Full Name*
First NameLast Name
Full Name*
First NameLast Name
Camper Information
Please fill out one form per camper
Full Name*
First NameLast Name
Jewish Name*
Birth Date*
MonthDayYear
School Attending*
Grade Entering*
Gender*
MaleFemale
Family Information
If you have have already registered one child you may leave this section blank.

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone
Area CodePhone Number
Father's Name
First NameLast Name
Father's Occupation
Father Jewish
YesNo
Father's Work Phone
Area CodePhone Number
Father's Cell Phone
Area CodePhone Number
E-mail
Mother's Name
First NameLast Name
Mother's Occupation
Mother Jewish
YesNo
Mother's Work Phone
Area CodePhone Number
Mother's Cell Phone
Area CodePhone Number
E-mail
Emergency Information
If you have have already registered one child you may leave this section blank.
Emergency Contact #1
First NameLast Name
Cell Phone
Area CodePhone Number
Relation to Camper
Emergency Contact #2
First NameLast Name
Cell Phone
Area CodePhone Number
Relation to Camper
Pediatrician
First NameLast Name
Phone Number
Area CodePhone Number
Special Needs
Questions/Comments
Important Information, Dates & Payment

1) A $150 deposit per child must accompany each registration. (Includes $60 non-refundable registration fee, ($75 after March 1) with the remaining balance to be applied toward camp tuition). The balance is due by May 31st. Please register early!

2) Scholarships are available. All requests for assistance must be received by May 15th. Please note that the deposit must be paid before you can be considered for assistance. Click Here to apply for a scholarship.

3) T-Shirts are required for all campers 5 and up and are optional for Mini Gan Campers.

2020 Dates

Full Session: June 15 - July 2

Week One: June 15 - June 19

Week Two: June 22 - June 26

Week Three: June 29 - July 2

Rates

Register Before:	March 1	May 15	June 20
Price:	Per Week / Full Session	Per Week / Full Session	Per Week / Full Session
All Ages:	$230 / $640	$245 / $685	$275 / $775
Registration Fee:	$60	$75	$75
T-Shirt Fee:	$15	$15	$15
Before Care:	$5 Day / $25 Week	$5 Day / $25 Week	$5 Day / $25 Week
After Care:	$9 Day / $45 Week	$9 Day / $45 Week	$9 Day / $45 Week

5% Sibling Discount!

My Child Will Attend*
Full Session (6/15-7/2)Week One (6/15-6/19)Week Two (6/22-6/26)Week Three (6/29-7/2))
Before Care
Week 1Week 2Week 36/156/226/296/166/236/306/176/247/16/186/257/26/196/26
After Care
Week 1Week 2Week 36/156/226/296/166/236/306/176/247/16/186/257/26/196/26
T-Shirt Size Youth
Youth SmallAdult SmallYouth MediumAdult MediumYouth LargeAdult Large
TERMS & CONDITIONS
PARENTAL CONSENT:I hereby give consent for my child to participate in all activities of Camp Gan Israel both on and off site, including trips, transportation to and from trips etc., unless I advise you otherwise in writing. PAYMENT AND CANCELLATION: Payment terms are a $50 non-refundable registration fee ($75 after March 1). Full tuition (Minus any scholarship) is due by May 31st, 2019 and is non-refundable after that date. DISMISSAL OF CAMPER:I fully understand and agree that Camp Gan Israel 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 his/her fellow campers or who violates camp rules and regulations. In the event of dismissal, tuition will be refunded on a pro-rated weekly basis less the $50 registration fee. MEDICAL CARE: In case of emergency, I hereby give permission to the physician selected by the camp director, to hospitalize, to secure proper treatment for and to order injection, anesthesia, or other procedure deemed necessary for my child by an MD. Every effort will be made to contact the Parent / Legal Guardian and emergency contacts first. Should it be necessary for the wellbeing of the camper to utilize outside medical or dental services, all expenses involved will be paid for by the parent. To the best of my knowledge, my child is in good health and I will notify the camp if he/she is exposed to any infectious diseases. I understand that my child may be dismissed during a camp day, due to illness, at the discretion of the camp, and I agree to abide by the Director’s decision. IMAGES, ETC.:Permission is hereby given to use in promoting the Camp and in other ventures directly relating to the Camp (I) digital, photographic and video images or likenesses of camper; audio of camper; and (II) statements, articles, names, music, art, photographs, audio recordings, films and videos created by camper or originating from Camp or from a Camp-related activity. INDEMNIFY & HOLD HARMLESS:I further release and agree to indemnify and hold harmless Camp Gan Israel (CGI) and its officers, servants or assigns from any liability or claim for any loss, injury, damage or expense resulting or arising from my child’s participation in camp activities. I further agree that the use of any premises during the CGI camp day is made at the risk of the registrant.
In addition, I acknowledge that the camp administration reserves the right to reconsider the enrollment of any camper if we feel the child’s needs or level of functioning or behavior cannot be accommodated, or if the child’s conduct limits his or her ability to participate in, or to benefit fully from, the program and activities at Camp Gan Israel. In addition, I acknowledge that I have read and accept the financial obligations and the refund policy as stated in the application form.
I Accept*
YesNo
Full Name*
First NameLast Name
Date*
MonthDayYear
A non refundable deposit of $150 - $60 registration + $90 of tuition per camper will be required by credit or debit card at the time of registration. (After March 1st it will go up to $175 - $75 Registration + $100 Tuition.) There will not be a processing fee for credit and debit card deposits and tuition payments made through May 1st 2020. Balance payments can be made by check. Once you have completed your registration, we will apply your early bird discount and send you a statement together with the health forms.
Total
$0.00

I would like to pay today: Full amount$150.00 minimum $

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Should be Empty:

Camper Information

Camper Information

Family Information

Emergency Information

Important Information, Dates & Payment

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