Camp Gan Israel

Winter Camp!

Winter Camp Registration Form
Child 1 Information
Full Name
First NameLast Name
Birth Date
MonthDayYear
School
Grade
Allergies
Medicare Number and Expiry Date
Child 2 Information
Full Name
First NameLast Name
Birth Date
MonthDayYear
School
Grade
Allergies
Medicare Number and Expiry Date
Parent 1 Information
Relationship to Child
Full Name
First NameLast Name
E-mail
Cell Number
Area CodePhone Number
Home Number
Area CodePhone Number
Work Number
Area CodePhone Number

Address

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

Parent 2 Information
Relationship to Child
Full Name
First NameLast Name
E-mail
Phone Number
Area CodePhone Number

Address if Different

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

Emergency Contact
Full Name
First NameLast Name
Phone Number
Area CodePhone Number
Registration & Payment
Price for the week: $160/week
Price per day: $45/day
Please select the days you want to register your child:
Child 1:
Monday, Dec 31, 2018Tuesday, Jan 1, 2019Wednesday, Jan 2, 2019Thursday, Jan 3, 2019
Child 2:
Monday, Dec 31, 2018Tuesday, Jan 1, 2019Wednesday, Jan 2, 2019Thursday, Jan 3, 2019
Total Amount

Payment

Credit Card

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

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