Camp Gan Israel Registration Form - Chabad of Waukesha-Brookfield

Please fill out this COMPLETELY and SIGN so that we can register your child(ren).

Click here for print version. Emergency Form Parent Handbook

PARENT INFORMATION

Mother's Name:*

First NameLast Name

Address:*

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

Cell Number:*

Area CodePhone Number

Work Number:

Area CodePhone Number

Home Number:*

Area CodePhone Number

E-mail:*

Father's Name:*

First NameLast Name

Address Same as above:

YesNo

Address (If different than above):

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

Cell Number:*

Area CodePhone Number

Work Number:

Area CodePhone Number

Home Number:*

Area CodePhone Number

E-mail:*

CAMPER INFORMATION

Camper 1:*

First NameLast Name

Gender:*

MF

Date of Birth:*

MonthDayYear

Grade (Fall 2021):*

Age:*

School Attending (Fall 2021):*

Sessions:*

Division:*

Mini Gan 3-4Grand Gan 5-10Pioneer Division 11-13

MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form for each child

In the past six months, has your child had any serious illnesses?*

NoYes

If yes, please list:

In the past six months, has your child been on any medications?*

NoYes

If yes, please list:

Does your child receive individualized assistance in school?*

NoYes

If yes, please list:

**If you are only registering one camper, please skip to "Emergency Contact Information"**

Camper 2:

First NameLast Name

Gender:

MF

Date of Birth:

MonthDayYear

Grade (Fall 2021):

Age:

School Attending (Fall 2021):

Sessions:

Division:

Mini Gan 3-4Grand Gan 5-10Pioneer Division 11-13

MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form for each child

In the past six months, has your child had any serious illnesses?

NoYes

If yes, please list:

In the past six months, has your child been on any medications?

NoYes

If yes, please list:

Does your child receive individualized assistance in school?

NoYes

If yes, please list:

Camper 3:

First NameLast Name

Gender:

MF

Date of Birth:

MonthDayYear

Grade (Fall 2021):

Age:

School Attending (Fall 2021):

Sessions:

Division:

Mini Gan 3-4Grand Gan 5-10Pioneer Division 11-13

MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form for each child

In the past six months, has your child had any serious illnesses?

NoYes

If yes, please list:

In the past six months, has your child been on any medications?

NoYes

If yes, please list:

Does your child receive individualized assistance in school?

NoYes

If yes, please list:

EMERGENCY CONTACT INFORMATION
Please list at least one emergency contact other than the child's parents.

1. Emergency Contact Name [other than parents]:*

First NameLast Name

Relationship to Child:*

Address:*

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

Home Phone*

Area CodePhone Number

Cell Phone*

Area CodePhone Number

2. Emergency Contact Name [other than parents]:

First NameLast Name

Relationship to Child:

Address:

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

Home Phone:

Area CodePhone Number

Cell Phone:

Area CodePhone Number

PHYSICIAN CONTACT INFORMATION

Name of Child's Physician or Medical Facility:*

Phone Number:*

Area CodePhone Number

Address:*

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

PAYMENT INFORMATION

DATES & RATES:

$225per week
WEEK 1: June 14-18
WEEK 2: June 21-25

$10 t-shirt fee

$35 lunch fee per week

Number of tshirts being ordered:$10/tshirt

Lunch Fee: (please select all that apply)

Total:

$0.00

Payment:

Credit Card Check or Scholarship Fund

Postal / Zip Code

Country

REGISTRATION POLICIES AND PARENTAL CONSENT

I hereby permit Camp Gan Israel to transport my child(ren) on camp provided transportation and to obtain emergency medical care as the situation mandates.

It is my responsibility to apply sunscreen on my child(ren) every morning before camp and to send along a labeled bottle for reapplication. However, in case of emergency, Rocky Mountain SPF 30 sunscreen is provided.

I am giving my permission for my child(ren) to participate in any pontoon/speed boating, horseback riding, ropes course, field trips, overnight trips and any other activity that is scheduled on the CGI calendar for his or her age group.

I allow Camp Gan Israel to photograph and/or videotape my child(ren) and to use these images for all promotional purposes.

The parent who signs this registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fees.

By typing my name and the date below, I certify that the information on this application is true and correct and that I have read, and approve, the policies listed above.

Full Name:*

First NameLast Name

Date:*

MonthDayYear