Camper/Parent Information |
Name
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First
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Middle
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Last
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Hebrew Name
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Address
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Street
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City
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State
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Zip
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Date of Birth
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Boy
Girl |
Contact Info
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Fathers Email
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Mothers Email
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Home Phone |
Full
Season 1
Season 2 |
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School
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Age:
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Grade completed this June
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Child's Mother
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Name
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Hebrew Name
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Work Phone
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Cell
Carrier
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Child's Father
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Name
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Hebrew Name
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Work Phone
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Cell
Carrier
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Child resides with:
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Persons authorized to pick up camper
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#1 Name
Phone Number
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#2 Name
Phone Number
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#3 Name
Phone Number
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#4 Name
Phone Number
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Name
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Phone
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Relationship
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Emergency Contact Info #2 1
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Name
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Phone
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Relationship
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Medical/Health Information |
Family Physician
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Name
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Phone
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Insurance Policy
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Policy#
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Medication
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Medication that your child takes regularly:
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Will this medication need to be dispensed at camp?
Yes No |
If yes please explain
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Health Issues
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Special dietary needs or restrictions:
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Any recent surgery or serious illness:
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List any allergies (food or medication) |
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Is your child prone to:
Ear infection Sinus infection
Other please explain |
Does your child have any mental or social handicap or any other problem of which we should be aware in caring for him/her? |
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General Information: |
Camper Info
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Camper’s strong likes and dislikes
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Camper makes friends:
Easily
Fairly well
With difficulty |
How does your child feel about going to camp this summer?
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Camper Info
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Are there any special situations or difficult transitions in your Child’s life (i.e.-moving, school, changes in family situations, etc.)? It is important for your child that you use this space to share this information with us |
What is the most important thing that you would like us to know about your child?
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Family Info
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Are the natural parent’s of the child/ren Jewish?
Mother Father |
Any conversions or adoptions in the family?
Yes No |
If yes please explain:
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Affiliation
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Are you affiliated with any Synagogue? Yes No
Name |
Does your child attend Hebrew school? Yes No
If yes name |
Swimming Info
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Does your child swim? Yes No |
Does your child have fear of water? Yes No |
Explain:
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T-Shirt Info
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I would like to buy T Shirts at $10.00 a T Shirt |
T-shirt size 6-8 10-12 14-16
Adult S Adult M Adult L |
N.A |
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You can now pay by Zelle to: [email protected]
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Payment Information: |
Payment type
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Visa Master Card
Cardholder's First Name Last Name
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Credit Card Info
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Number
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Expiration Date
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Amount to charge: 4 |
CVV |
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Comments: |
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Where did you hear about Camp Gan Israel?
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IMPORTANT |
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I will mail or bring in a copy of my child’s immunization records and child’s health examinations forms (blue and Yellow). Registration is not complete without this. |
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I give my permission to use the photograph of my child as well as myself for promotional purposes. Camp group list can be disseminated with campers and parents names and phone numbers. |
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My child has my permission to participate in Camp Gan Israel Day Camp. I understand that this program includes field trips and activities off the premises. |
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I understand that in case of emergency and I am unable to be contacted, I give permission to Camp Gan Israel to authorize any emergency action necessary to insure the safety of my child. |
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I understand that by participating in any Camp Gan Israel activities and use of any recreational facilities involves risk of accidental injury despite all safety precautions. Having been informed of the activities to be conducted by the Camp Gan Israel, I/ We as an individual or as a parent or guardian of the participants named herein, assume all risk and hazards incidental to the activities and release from responsibility and agree to indemnify and hold harmless the Camp Gan Israel, its officers, directors, independent contractors, volunteers and all employees for any illness or injury to me or my children or family members occurring during his/her/our participation in any activities or use of any facilities at or conducted by Camp Gan Israel. |
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I understand that all deposits are non refundable. |
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I understand that by enrolling in Camp Gan Israel I am agreeing to abide by all its policies. |
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I have read the parent handbook and application form and agree to the terms stated. |
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Date of Application: Initials: |