| Parent Information |
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Child's Mother
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First Name |
Last Name |
Cell #
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Email |
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Child's Father
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First Name |
Last Name |
Cell #
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Email |
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Address
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Street |
City |
State |
Zip |
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Phone
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Home Phone
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Alternate Phone
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List a friend/relative below who has agreed to assume temporary care of your child(ren) if you cannot be reached: |
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Emergency Contact Info
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Name
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Phone |
Relationship |
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Pediatrician
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Name
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Phone |
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| Camper #1 Information |
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Name
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First
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Last (if different from parents) |
Boy Girl |
Hebrew
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Date of Birth
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Hebrew DOB
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Schools
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School |
Hebrew School |
Grade Completed as of 6/10:
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Swimmer
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Good Fair Poor
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Special Instructions:
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Medical
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Allergies & Medical Note:
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Age Group as of June 2010: |
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Ages 10-12 (Girls only) |
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Ages 3-4 |
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Ages 4-9 |
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Ages 2-3 |
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Please indicate number of sessions your child will attend camp:
Dates for Summer 2010: June 23-August 3 - check all that apply
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Full Session June 23- Aug 3
Week 1 June 23 - June 25
Week 2 June 28 - July 2
Week 3 July 5 - 9
Week 4 July 12 - 16
Week 5 July 19 - 23
Week 6 July 26 - 30
Week 7 Aug 2 - 3
+ Pre school Aftercare 2-4 pm $25/week (5 days)
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Comments:
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| Camper #2 Information |
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Name
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First
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Last (if different from parents) |
Boy Girl |
Hebrew
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Date of Birth
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Hebrew DOB
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Schools
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School |
Hebrew School |
Grade Completed as of 6/10:
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Swimmer
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Good Fair Poor
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Special Instructions:
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Medical
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Allergies & Medical Note:
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Age Group as of June 2010: |
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Ages 10-12 (Girls only) |
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Ages 3-4 |
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Ages 4-9 |
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Ages 2-3 |
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Please indicate number of sessions your child will attend camp:
Dates for Summer 2010: June 23-August 3 - check all that apply
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Full Session June 23- Aug 3
Week 1 June 23 - June 25
Week 2 June 28 - July 2
Week 3 July 5 - 9
Week 4 July 12 - 16
Week 5 July 19 - 23
Week 6 July 26 - 30
Week 7 Aug 2 - 3
+ Pre school Aftercare 2-4 pm $25/week (5 days)
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Comments:
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| Camper #3 Information |
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Name
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First
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Last (if different from parents) |
Boy Girl |
Hebrew
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Date of Birth
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|
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Hebrew DOB
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Schools
|
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School |
Hebrew School |
Grade Completed as of 6/10:
|
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Swimmer
|
|
Good Fair Poor
|
Special Instructions:
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|
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Medical
|
Allergies & Medical Note:
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Age Group as of June 2010: |
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|
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Ages 10-12 (Girls only) |
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Ages 3-4 |
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Ages 4-9 |
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Ages 2-3 |
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Please indicate number of sessions your child will attend camp:
Dates for Summer 2010: June 23-August 3 - check all that apply
|
| |
Full Session June 23- Aug 3
Week 1 June 23 - June 25
Week 2 June 28 - July 2
Week 3 July 5 - 9
Week 4 July 12 - 16
Week 5 July 19 - 23
Week 6 July 26 - 30
Week 7 Aug 2 - 3
+ Pre school Aftercare 2-4 pm $25/week (5 days)
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Comments:
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| Camper #4 Information |
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Name
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First
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Last (if different from parents) |
Boy Girl |
Hebrew
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Date of Birth
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Hebrew DOB
|
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Schools
|
|
School |
Hebrew School |
Grade Completed as of 6/10:
|
|
Swimmer
|
|
Good Fair Poor
|
Special Instructions:
|
|
|
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Medical
|
Allergies & Medical Note:
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Age Group as of June 2010: |
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|
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Ages 10-12 (Girls only) |
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Ages 3-4 |
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Ages 4-9 |
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Ages 2-3 |
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Please indicate number of sessions your child will attend camp:
Dates for Summer 2010: June 23-August 3 - check all that apply
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Full Session June 23- Aug 3
Week 1 June 23 - June 25
Week 2 June 28 - July 2
Week 3 July 5 - 9
Week 4 July 12 - 16
Week 5 July 19 - 23
Week 6 July 26 - 30
Week 7 Aug 2 - 3
+ Pre school Aftercare 2-4 pm $25/week (5 days)
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Comments:
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| IMPORTANT - READ CAREFULLY |
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All forms must be completed and submitted before your child begins camp. |
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Conditions: Registration is accepted only with registration fee of $50 per session. Applications without this fee will be placed on the camp waiting list, with no guarantee of placement. The fee will be applied towards camp tuition. Full camp fees must be paid prior to each session. Refunds depend upon date of applicant’s cancellation. Medical Certificate must be signed and turned in to the office. Gan Israel will make every effort to insure the well-being of every camper. However, it will not be responsible for any injury or health impairment of any camper. Gan Israel will not be responsible for damage to or loss of clothing or personal belongings of any camper.
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My child has permission to participate in all Gan Israel supervised activities including swimming and field trips. If I cannot be contacted in the case of an emergency, Gan Israel has the authority to seek medical attention for my child.
I fully understand the above terms. I have notified Gan Israel as to all information requested, as well as any other important facts needed to be known for my child's welfare.
Scholarship requested - turn in separate scholarship application available here.
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I heard about Camp Gan Israel from: |
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Date of Application: Initials: |