CAMP GAN ISRAEL APPLICATION FORM SUMMER 2022 - 5782Campers InformationFamily Name:*English Name:*Hebrew Name:Gender:*BoyGirlDate of Birth*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearSchool:Grade Before Summer:*Contact InformationChild is in care of:ParentsMotherFatherGuardianBest contact phone:Address:City:Postal Code:Father's InformationEnglish Name:Hebrew Name:Father is:JewishNot JewishHome Phone:Cell Phone:Work Phone:E-mailMother's InformationEnglish Name:Hebrew NameMother is:JewishNot JewishHome Phone:Cell Phone:Work Phone:E-mailEmergency contact other than parent/guardianEmergency contact name:RelationshipPhoneMedical InformationFamily Medical Number:*(6 digit)Camper's Personal Health ID:*(9 digit)Camper's Doctor:Doctor's Tel #:Doctor's Address:Describe any medical information the camp should be aware of, such as allergies, medications, or any other concerns or special needs of your child:Program InformationSessions AttendingFull Camp (July 4- July 29) $500First Session (July 4- July 15) $300Second Session (July 18 - July 29) $300Other - see comment belowExtra CareNot NeededA.M. (8:30-9:30) > add $25/weekP.M. (4:00-5:00) > add $25/weekBoth a.m. & p.m. > add $50/weekPayment ScheduleCharge the total fee now$150 application deposit. Balance to be paid by july 5thother, please see comment belowSubsidyI am able to pay the full priceI will pay the subsidized price (20% less)other, please see comment belowPayment Type*Credit Card I Will Send A Cheque Credit CardWe accept Visa, MasterCardCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2023202420252026202720282029203020312032Expiration YearPlease enter any comments you have here:Click the button below to submit your child's application. Please note that your child's participation is not guaranteed until you receive a confirmation email from camp.Submit Clear FormShould be Empty: This page uses TLS encryption to keep your data secure.
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