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Online Registration Teen Extreme!

Click here  for Dates and Rates 

 

Family Information
Family Name
  
     
Address
   Street
City
State
Zip
Email Address
   Mother Email 
Father Email
 
Parents Marital Status           
Mother
  Mother's Name 
Is mother Jewish?
Yes No 		 Work Phone 
 		 Cell 
Address (if different) 
   Street City State

Zip

 
Father
   Father's Name
Is father Jewish?
Yes No 		Work Phone
Cell
Address (if different)    Street  City State
Zip 
Emergency Contact Info (to be used only when parents can't be reached)  

1)
   Name
Phone
Relationship
 
Pediatrician
   Name
Phone
   
Insurance    Company 
 		 Policy # 
 		    
Camper 1 Information
      
Name
   First Name
Middle Name
 Gender
 
Date of Birth
    
School
   School
Entering Grade:
 		  
Quick Health Notes
   Medication
 		 Allergies
   
 
   Health Problems or Disabilities
     

Sessions attending

  

 full summer session

week 1 session 2 session 3  session 4

Optional 

  

 transportation from Northbrook & surrounding suburbs $45 a session ($175 summer season)

 transportation from all other areas $50 a session ($195 summer season)

Camper 2 Information (optional)
      
Name
   First Name
Middle Name
 Gender
 
Date of Birth
    
Schools
   School
Entering Grade:
 
Quick Health Notes
   Medication
 		 Allergies
   
 
   Health Problems or Disabilities
     

Sessions attending

  

summer season

session 1 session 2 session 3 session 4 

Optional 

  

 transportation from Northbrook & surrounding suburbs $45 a session ($175 summer season)

 transportation from all other areas $50 a session ($195 summer season)

       
PAYMENT INFORMATION
Payment Method 
 CREDIT CARD  
CHECK (Registration is not confirmed until we receive the check.)

Credit Card  

 

 

 

 

 

 

Please enter your credit card information.

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Card type:  Mastercard Logo Visa Logo Amex Logo Discover Logo.JPG 
Name on Card:  
Card Number:  
Expiration Date:    
CVV Security Code:  

What's This?

I authorize Camp Gan Israel to charge my card the non-refundable deposit in the amount of $  

*Optional*  I authorize Camp Gan Israel to charge my card for the full amount of the camp tuition $  

   

Check		 Registration is not complete until we receive a $200 non-refunable deposit for each child.  
Please mail checks to: 
Camp Gan Israel
2833 W Howard St.
Chicago, IL 60645

 

 

I have read and agree to the  terms and conditions. I authorize Camp Gan Israel, to have my child treated in case of emergency by a physician in the manner such person deems necessary.  I further give permission for my child to attend and be transported on camp trips.

I understand that full payment is required for all registrations by June 10, 2018. 

 


 

 Date of Application:   
Initial here in lieu of signature  
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