Apply

Before proceeding be sure to visit Camp Rates
You will be required to pay the registration fee when submitting this application.

Please fill out carefully.
When you press submit, this form will be sent to our administration office.
Please look out for our letter of acceptance.
Full Name Name of Parent/Guardian filling out this application
First Name Last Name
Email* For application confirmation and status
Phone Number*

Address*

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

1. Child/ren’s Information
How many of your children are applying?*
Child 1*
First Name Hebrew Name Last Name
Birth Date* child 1

Month Day Year
Gender* child 1

MaleFemale
Sessions* child 1

Week 1Week 2Week 3Week 4
Child 2*
First Name Hebrew Name Last Name
Birth Date* child 2

Month Day Year
Gender* child 2

MaleFemale
Sessions* child 2

Week 1Week 2Week 3Week 4
Child 3*
First Name Hebrew Name Last Name
Birth Date* child 3

Month Day Year
Gender* child 3

MaleFemale
Sessions* child 3

Week 1Week 2Week 3Week 4
Child 4*
First Name Hebrew Name Last Name
Birth Date* child 4

Month Day Year
Gender* child 4

MaleFemale
Sessions* child 4

Week 1Week 2Week 3Week 4
If you have more than 4 children please contact us.
2. Parent information
Mother's info
First Name Hebrew Name Last Name
Work Phone
E-mail
Cell Phone
Father's info
First Name Hebrew Name Last Name
Work Phone
E-mail
Cell Phone
Phone Number*
How did you hear of us?
Is child's natural mother jewish?*

YesNo
Is child's natural father jewish?*

YesNo
Have there been any conversions or adoptions* Grandparents included

Yes (Please specify)No
Comments
3. Emergency Information
Any allergies or concerns*

Yes - Please specifyNo
Allergy Info
Emergency Contact*
First Name Last Name
Relationship*
Pediatrician & Insurance
First Name Last Name
Phone Number
Insurance
Policy #
4. Payment Information
Time of submission

Month Day Year
at Hour Minutes
$85 Non-refundable registration fee* $50 goes towards camp tuition

$85 - 1 Child$170 - 2 Children$255 - 3 Children$340 - 4 Children
$135 Non-refundable registration fee* $50 goes towards camp tuition

$135 - 1 Child$270 - 2 Children$405 - 3 Children$540 - 4 Children
Non-refundable Registration fee ($50 of registration fee is applied to camp tuition)
$85 for early bird submissions.
$135 for non early bird
Camp tuition: see Dates & Rates
Tuition Agreement*

I have reviewed the tuition rates listed in the Dates & Rates page and agree to pay the amount for my child/ren to attend Camp Gan Izzy
Tuition* Amount of tuition I want to pay now

$0
Total

$0.00

Payment

Credit Card Paypal

Postal / Zip Code

Country

Agreement*

I am signing up my child for camp. I give my child permission to attend all trips and receive medical care in the case of emergency, G-d forbid. I give Gan Israel permission to photograph and videotape my children and use the photos and videos (without their names) for whatever the camp sees fit.
General comments
Should be Empty:

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1. Child/ren’s Information

2. Parent information

3. Emergency Information

4. Payment Information