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New Camper Registration

New Camper Registration

SUMMER CAMP 2017 REGISTRATION FORM

If your child attended camp last year (2016) and is returning to camp this summer (2017)
please click here to fill out our abbreviated Returning Camper Registration Form

To PRINT our Registration Form click here

General Information

Gender

Camp Program Attending:

Age at Camp 2017 

First Name

Hebrew First Name

Last Name

Date of Birth (month/day/year)

School Grade Entering Fall 2017 (upcoming school year) 

Family Information:

Mother's Name

Mother's Address

Mother's Email

Mother's Home Phone

Mother's Cell Phone

Mother's Work Phone

Father's Name

Father's Address (only enter fields that are different than above)

Father's Email

Father's Home Phone

Father's Cell Phone

Father's Work Phone

Emergency Contact:

Name

Relationship

Home Phone

Cell Phone

Work Phone

Additional Information you would like to provide:


Please select the dates your child will be attending camp, or simply select the total amount of weeks you are registering your child if you don't wish to specify which weeks at this time.

Session Attending Pre-Care After Care
1. June 26 - June 30
2. July 3 - July 7
3. July 10 - July 14
4. July 17 -  July 21

Total Amount of Weeks Attending (1, 2, 3, or 4):

Medical Consent

Dear Parent/Guardian,

Your son/daughter is below legal age of consent. The law requires that we have your permission if medical service should be needed. Your completion of this consent form will authorize us to proceed with the care of lesser types of medical problems which may occur. In the event of any major health problems, we will notify you as promptly as possible and follow your instructions. If we are unable to contact you or your alternative contacts listed below, your child will be taken to the nearest Emergency Room Facility and will be treated there.

 

In the event of an emergency when a parent/guardian is unavailable, I hereby authorize a representative of Camp Gan Israel to make such arrangements as considered necessary for my child to receive medical or hospital care, including transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment as considered necessary. In the event such physician is not available, I authorize such care and treatment to be performed by any licensed physician or surgeon.

 

Physician’s Name

Physician’s Phone Number
Insurance Provider

Medical Insurance Number

I do not choose the above. I desire the following action to be taken in the event of an emergency:



I agree (name) to bear all costs as a result of the foregoing.

 

As parent/guardian, (name) I agree to the terms above.


Please provide any allergy or other medical information we should know.

MAIN CAMP
TRIP RELEASE
FORM

 


I agree (name) to allow my child to participate in all off-campus activities, trips and activities (where applicable).

IMAGES

CGI Cobb and Chabad of Cobb are hereby granted permission to use any individual or group camp photos and or videos showing our children involved in camp activities.




PAYMENT OPTIONS (For rates click here)

Terms of agreement: (please check one)

Payment Method (All payments due before camp begins)

Check Credit Card

Payment Plan:

Full Payment
 4 equal consecutive monthly payments (for registration received by March 1, 2017)

 3 consecutive monthly payments (for registration received by April 1, 2017)
2 equal consecutive monthly payments (for registration received by May 1, 2017)

Credit Card Information
Visa MC Amex Number


Ex Date (month/year)


CVV Security

Name on Card

Street Address and Zip Code where the bill is sent


Enrollment Agreement

I agree to the terms of enrollment and information listed above.
My name (Parent or Legal Guardian)

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