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Online Registration Jewish Alaskan Adventure!

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
 
2)
  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
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
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 July 1, 2016.


Date of Application:
Initial here in lieu of signature
  Comments