Camper InformationFull Name*First NameLast NameFull Name*First NameLast NameFull Name*First NameLast NameFull Name*First NameLast NameFull Name*First NameLast NameCamper InformationPlease fill out one form per camperFull Name*First NameLast NameJewish Name*Birth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearSchool Attending*Grade Entering*Gender*MaleFemaleFamily InformationIf you have have already registered one child you may leave this section blank.AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / 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 SaharaYemenZambiaZimbabweOtherCountryHome PhoneArea CodePhone NumberFather's NameFirst NameLast NameFather's OccupationFather JewishYesNoFather's Work PhoneArea CodePhone NumberFather's Cell PhoneArea CodePhone NumberE-mailMother's NameFirst NameLast NameMother's OccupationMother JewishYesNoMother's Work PhoneArea CodePhone NumberMother's Cell PhoneArea CodePhone NumberE-mailEmergency InformationIf you have have already registered one child you may leave this section blank.Emergency Contact #1First NameLast NameCell PhoneArea CodePhone NumberRelation to CamperEmergency Contact #2First NameLast NameCell PhoneArea CodePhone NumberRelation to CamperPediatricianFirst NameLast NamePhone NumberArea CodePhone NumberSpecial NeedsQuestions/CommentsImportant Information, Dates & Payment1) 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 DatesFull Session: June 15 - July 2Week One: June 15 - June 19Week Two: June 22 - June 26Week Three: June 29 - July 2RatesRegister Before:March 1May 15June 20Price:Per Week / Full SessionPer Week / Full SessionPer Week / Full SessionAll Ages:$230 / $640$245 / $685$275 / $775Registration Fee:$60$75$75T-Shirt Fee:$15$15$15Before Care:$5 Day / $25 Week$5 Day / $25 Week$5 Day / $25 WeekAfter Care:$9 Day / $45 Week$9 Day / $45 Week$9 Day / $45 Week5% 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 CareWeek 1Week 2Week 36/156/226/296/166/236/306/176/247/16/186/257/26/196/26After CareWeek 1Week 2Week 36/156/226/296/166/236/306/176/247/16/186/257/26/196/26T-Shirt Size YouthYouth SmallAdult SmallYouth MediumAdult MediumYouth LargeAdult LargeTERMS & CONDITIONSPARENTAL 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*YesNoFull Name*First NameLast NameDate*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$0.00I would like to pay today: Full amount$150.00 minimum $ PaymentCredit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2021202220232024202520262027202820292030Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / 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 SaharaYemenZambiaZimbabweOtherCountryClick to edit this text...SubmitShould be Empty: This page uses TLS encryption to keep your data secure.