ב"ה

CGI Application

Please fill out the form below carefully. When you press submit, this form will be sent to our administration office.
Note: Please use a separate form for each child.
Camper/Parent Information:
Camper's Full Name*

First Name Last Name
Camper's Hebrew Name*

First Name Middle Name
Camper's Preferred Name:*

First Name Last Name

Address*

Date of birth:*

Month Day Year
School: *
Hebrew school:*
Entering grade:*
Mother's name*

First Name Last Name
Mother's Hebrew name*

First Name Last Name
Is Mother Jewish
Mother's cell phone:

Area Code Phone Number
Mother's E-mail:
Father's name*

First Name Last Name
Father's Hebrew name*

First Name Last Name
Is Father Jewish
Father's cell phone:

Area Code Phone Number
Father's E-mail:
Emergency contact:*

First Name Last Name
Emergency contact phone number:*

Area Code Phone Number
Relationship to child:*
Please note any medical issues or behavioral differences:
Any allergies? If yes, please specify:
Pediatrician:*

First Name Last Name
Pediatrician's phone number:*

Area Code Phone Number
Child's age:*

Age 5Age 6Age 7Age 8Age 9Age 10Age 11Age 12
Please choose your session:*

1 Week Session2 Weeks SessionFull Session(3 Weeks)
Payment Options:*

Deposit $2001 Week Session - $4502 Weeks Session - $900Full Session (3Weeks) - $1350
Please Indicate which session you child will attend camp (choose all that apply)*

Week 1 - July 22 - 26Week 2 - July 29 - Aug 2Week 3 - Aug 5 - 9
Important: All forms must be completed and submitted before your child begins camp.
*

I have read the camp brochure and application form and agree to the terms stated. I give my child permission to attend all trips, and receive medical care in the case of emergency.I Hereby authorize Camp Gan Izzy to Video and photograph my child and to use images for educational and promotional purposes.
Payment Information:
Total

$0.00

Payment*

Credit Card Check

Postal / Zip Code

Country

This page uses TLS encryption to keep your data secure.

Camper/Parent Information: