1. Child/ren’s Information Dates: June 24, 2024 - July 12, 2024 Kiddie Camp: Ages 2-5 Older Camp: Ages 6-13 *Contact us for Junior Counselor positions, for teens ages 14+! Monday-Friday 9:30 am-3:00 pm Child 1* First Name Middle Name Last Name Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Grade Entering* 18 mo (if older sibling is attending kiddie camp) Preschool Pre-K Kindergarten 1 2 3 4 5 6 Gender* MaleFemale Weeks Attending ($250/week)* Week 1Week 2Week 3 Camp t-shirt size* Youth XS Youth S Youth M Youth L Youth XL Adult XS Adult S Adult M Adult L Adult XL Child 2 First Name Middle Name Last Name Birth Date 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Grade Entering 18 mo (if older sibling is attending kiddie camp) Preschool Pre-K Kindergarten 1 2 3 4 5 6 Gender MaleFemale Weeks Attending ($250/week) Week 1Week 2Week 3 Camp t-shirt size Youth XS Youth S Youth M Youth L Youth XL Adult XS Adult S Adult M Adult L Adult XL Child 3 First Name Middle Name Last Name Birth Date 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Grade Entering 18 mo (if older sibling is attending kiddie camp) Preschool Pre-K Kindergarten 1 2 3 4 5 6 Weeks Attending ($250/week) Week 1Week 2Week 3 Gender MaleFemale Camp t-shirt size Youth XS Youth S Youth M Youth L Youth XL Adult XS Adult S Adult M Adult L Adult XL 2. Parent Information Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Mother's Info First Name Last Name Work Phone Area Code Phone Number E-mail* Primary email Cell Phone Area Code Phone Number Father's Info First Name Last Name Work Phone Area Code Phone Number E-mail* Cell Phone Area Code Phone Number How did you hear of us? Email Facebook Internet Search Attended Previously Other 3. Emergency Information Emergency Contact* First Name Last Name Phone Number* Area Code Phone Number Relationship* Additional authorized persons to pick up my child: Full Name First Name Last Name Cell Phone Area Code Phone Number Full Name First Name Last Name Cell Phone Area Code Phone Number *This is on the Medical Form as well* In case of an accident or serious illness involving my child whenever the child is in attendance at Camp Gan Israel, I request The Camp to telephone me at the above listed telephone. If in the judgment of The Camp, delay entailed in telephoning me or other persons named above would not be in the best interest of my child, I hereby authorize The Camp before telephoning me to take my child to any physician or surgeon selected by The Camp and licensed under the provision of the California Medical Practice Act, to any physician or surgeon selected by the director for such action as such physician or surgeon deems necessary or advisable in the circumstances. I hereby consent to any and all diagnostic procedures, examinations, care and treatment (including without limitation, X-ray examination, anesthetic and emergency surgical intervention) as any such physician or surgeon may deem necessary or advisable, whether such diagnostic procedure, examination, care or treatment is rendered at the office of such physician, surgeon or dentist or at a hospital or clinic. I understand that this authorization is given in advance of any specific diagnosis, examination, care or treatment being rendered and is given to provide authority and power on the part of any such physician or surgeon to render any and all such diagnostic procedures, examinations, care or treatment that he or she may deem necessary or advisable. I certify that no information concerning the health of this counselor/camper has been withheld or misrepresented. I authorize our physician to provide further medical history should it be deemed necessary. This completed form may be photocopied for trips out of camp. I hereby give permission, for my child registered in any of the Monday – Friday programs of Camp Gan Israel, to be taken by school bus on all outings and trips. I give permission to Camp Gan Israel to use camp photos of my child/ren in any camp publicity. I understand that refund of payment is subject to Camp Gan Israel refund policies, as written in the parent handbook. Agreement* I agree Name* Initials* 4. Payment Information Total $0.00 Payment* Credit Card Paypal Check Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Expiration Year Paypal has been selected. Payment will take place on the next page. Any notes or additional info: Registration is not complete until the medical form is filled out for each child. A form will be emailed to you via DocHub to fill out online. You can also access the medical form here if you would like to fill out a printed copy and mail it to the office. Should be Empty: Submit This page uses TLS encryption to keep your data secure.