Please fill out the form below carefully. When you press submit, this form will be sent to our administration office. There is a $35 registration fee per child.

Note: Please use a separate form for each child.

Camper/Parent Information
Name
   First
Middle
Last
 
Address
   Street
City
State
Zip
Date of Birth
    
Contact Info
   Phone
Email
 
Schools
   School
Hebrew School Entering Grade:
Child's Mother
   Mother's Name
Hebrew Name Work Phone Cell
Child's Father
   Father's Name
Hebrew Name Work Phone Cell
Emergency Contact Info
   Name
Phone
Relationship
 
Pediatrician
   Name
Phone
   

Email

      
           
Select Child's Age Group
    Ages 5-6 Ages 7-8  
  Ages 9-10 Ages 11-12    
   

Please indicate days your child will attend camp: June 17- July 12

Week 1: 6/17-6/21 Week 2: 6/24-6/28 Week 3: 7/1-7/5 Week 4: 7/8-7/12
 
     
Medical Forms
The Medical Form must be filled out and sent to
Gan Israel of Lake Worth 5801 Colbright Rd • Lake Worth, FL 33467
 
IMPORTANT
  All forms must be completed and submitted before your child begins camp.
Please charge my card below the $35 registration fee:
 
Card Number Card Type
Exp Date CVV Code
   

I give my permission to use the photograph of my child for promotional purposes. Your child’s photographic image may thereafter appear on our camp / Chabad website, publications, newspapers or newscasts.
My child has my permission to participate in Camp Gan Israel Day Camp. I understand that this program includes field trips and activities off the premises.
I understand that in case of emergency and I am unable to be contacted, I give permission to Camp Gan Israel to authorize any emergency action necessary to insure the safety of my child.
I understand that by participating in any Camp Gan Israel activities and use of any recreational facilities involves risk of accidental injury despite all safety precautions. Having been informed of the activities to be conducted by the Camp Gan Israel, I/ We as an individual or as a parent or guardian of the participants named herein, assume all risk and hazards incidental to the activities and release from responsibility and agree to indemnify and hold harmless the Camp Gan Israel, its officers, directors, independent contractors, volunteers and all employees for any illness or injury to me or my children or family members occurring during his/her/our participation in any activities or use of any facilities at or conducted by Camp Gan Israel.
I understand that full payment is due by June 1rst at which time the balance of tuition becomes non-refundable, and refunds will not be made for incomplete attendance.
I understand that by enrolling in Camp Gan Israel I am agreeing to abide by all its policies.
  Parent Initials Date of Application: