Registration experience the summer of your lifetime Please enter your details to register today. How many children are you registering?123Child 1 Name* First Last Hebrew NameDOB* Date Format: MM slash DD slash YYYY Age*Gender*BoyGirlSchool*Grade Entering*KindergartenFirstSecondThirdFourthFifthSixthSeventhSecond ChildChild 2 Name* First Last Hebrew NameDOB* Date Format: MM slash DD slash YYYY Age*Gender*BoyGirlSchool*Grade Entering*KindergartenFirstSecondThirdFourthFifthSixthSeventhThird ChildChild 3 Name* First Last Hebrew NameDOB* Date Format: MM slash DD slash YYYY Age*Gender*BoyGirlSchool*Grade Entering*KindergartenFirstSecondThirdFourthFifthSixthSeventhPrevious Jewish Education?YesNoWhere?Is the natural mother of the Child(ren) Jewish?*YesNoWere there any conversions or adoptions in the Family?*YesNoPlease provide details:Parent InformationFather's Name* First Last Hebrew NameHome PhoneFather's Cell*Father's Email* Occupation*Mother's Name* First Last Hebrew NameHome PhoneMother's Cell*Mother's Email* Occupation*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Synagogue affiliated with (if any):Persons to be contacted in case of an emergency when parents cannot be reached. Please provide two contacts.Name 1* First Last Phone*Relationship to child*Name 2 First Last PhoneRelationship to childCONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of?*YesNoPlease describe them and indicate special precautions or care needed.Early Bird Special! Yes, I'm registering before June 6, 2019 and would like to receive the 10% discount. Please choose one of the following payment options:* 1. One Full Camp Payment 3. No Charge Payment Method*Please Bill MePlease Charge My Card BelowNo ChargeCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name Amount To Charge* As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Gan Israel of Your City to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Gan Israel of Your City personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Gan Israel of Your City activities and that these pictures may be used for marketing purposes.* I Accept Name*Initials*We look forward to a fantastic summer camp season!
