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Online Registration

Parent Information:
Father:
Title:
Full Name:
First Name Last Name
Work Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
E-mail:
Mother:
Title:
Full Name
First Name Last Name
Marital Status:
Work Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
E-mail:
Have there been adoptions or conversions in the family?

YesNo
If yes, please explain:
Choose a Session:
Please select:

Camp Gan Izzy - 9:00 am - 3:30 pmMini Gan - 9:00 am - 12:30 pm
Regular Gan Izzy - Select one or more:*

Week 1: June 30 - July 4Week 2: July 7 - July 11Week 3: July 14 - July 18All 3 Weeks: June 30 - July 18Daily registration - $40/day
Mini Gan - Select one or more:*

Week 1: June 30 - July 4Week 2: July 7 - July 11Week 3: July 14 - July 18All 3 Weeks: June 30 - July 18Daily registration - $20/day
Regular Gan - My child will be attending:

June 30July 1July 2July 3July 4July 7July 8July 9July 10July 11July 14July 15July 16July 17July 18
Mini Gan - My child will be attending:

June 30July 1July 2July 3July 4July 7July 8July 9July 10July 11July 14July 15July 16July 17July 18
Camper Information:
Full Name:*
First Name Last Name
Hebrew Name:
Gender:*
Date of Birth:*

Month Day Year

Address:*

Home Phone Number:

Area Code Phone Number
School:*
Grade Entering:*
Notes/Comments:
Medical Information:
Physician Name:
Physician Phone:

Area Code Phone Number
Insurance:
Insurance Number:
Allergies:
Does your child take regular medication? If yes, please specify.
Does your child have any medical conditions we should be aware of?
Medical Note:
Emergency Information:
Emergency Contact #1:*
Full Name:*
First Name Last Name
Phone Number:*

Area Code Phone Number
Relation:*
Emergency Contact #2:
Full Name:
First Name Last Name
Phone Number:

Area Code Phone Number
Relation:
Immunization Information:
For campers who reside within the United States, a United States territory, or the District of Columbia:
State/Territory in which child resides:
Is this child exempt from any immunizations?
If yes, please list them:
Payment Information:
Total:

$0.00

Payment:

Credit Card Other

Postal / Zip Code

Country

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Camp Gan Israel to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Camp Gan Israel personnel will try, but are not required, to communicate with me/us prior to such treatment.
I Agree to the terms and conditions above.
Parent/Guardian Name:
Date:

Month Day Year
100% of the proceeds of this donation or payment benefit Chabad of Venice & North Port.
Should be Empty:

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Parent Information: