Gan Izzy Day Camp - Registration Form

Please complete the entire form

Campers info:

Last Name

First Name: 

Hebrew Name: 

Date Of Birth: Gender: 

Home Address: 

City:  State:  Zip Code: 

Home Phone: 


School Sept. 2015:  Entering Grade: 

Fathers Name:  Cell Phone: 

Mothers Name:  Cell Phone: 

Emergency Contact Name:  Cell Phone: 

Doctor Name:  Doctor Phone: 

Specific Health Notes- if applicable 

Session and fee schedule:

Week one: July 20- July 24 $100 

Week two: July 27 - July 31 $100 


Payment information

Credit Card Type: 

Name on card: 

Credit Card Number: 

Ex. Date (Day/Month): 



In case of emergency, I request Camp Gan Israel Day Camp to contact me. If the camp is unable to reach me, I hereby authorize the camp to call the physician indicated above and to follow his instructions. If camp cannot contact this physician, the camp may make whatever arrangements seem necessary. I hereby give permission for campers to attend all the field trips the camp will be taking. I understand that the camp will provide transportation, and that safety precautions will be taken at all times. Gan Israel will make every effort to insure the well-being of every camper. However, it will not be responsible for any injury or health impairment of any camper.


I Agree 


Any comments or concerns: