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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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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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