Online Registration! 
Camp Gan Israel winter Camp 2010  February 16-18 

Please fill out the form below carefully. When you press submit, this form will be sent to our administration office.  PLEASE NOTE:  APPLICATIONS ARE BEING ACCEPTED ON A FIRST COME FIRST SERVE BASIS.  Space reserved once deposit is received.  QUESTIONS? CALL 516-295-2478 EXT. 19. 

Note: Please use a separate form for each child.

Child's Information
Name
  

Child's first name
Last Name

Hebrew Name

   
Address
   Street
City State
Zip
Date of Birth
    
Contact Info
   Phone
Email
 
Schools
   School
Hebrew School Entering Grade:
Child's Mother
   Mother's Name
Occupation Work Phone Cell
Child's Father
   Father's Name
Occupation Work Phone Cell
Emergency Contact Info
  

Name

Name

Phone Phone

Relationship Relationship

 
Pediatrician
   Name
Phone    

Email

      
     
Please use the space provided below to describe your child's physical strengths and or weaknesses (physical, emotional, intellectual):       
   
Does your child have any special needs/ services/ therapist we should be aware of?    
Does your child have any allergies?    
 
  
Please indicate number of days your child will attend camp:
 
     
IMPORTANT
 

Fee $45 per a day (includes hot lunch and snacks
 
•
I will be paying by: Check Mastercard Visa  
 

CC#  
Expiration   CW#  

  Charge my card now a total of  (Payment in full before May 3rd)
Payments are non refundable! I have read the camp brochure and application form and agree to the terms stated. I give my child permission to receive medical care in the case of emergency.
   
  Date of Application: