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Camper Information
Camper 1
Name: Birthday: Age:
Grade Entering: Name of School:  
 
Camper 2
Name: Birthday: Age:
Grade Entering: Name of School:  
 
Camper 3
Name: Birthday: Age:
Grade Entering: Name of School:  

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Parent Information
Name:
Email:
Phone:
Address:
City/State/Zip:

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Emergency Information
Emergency Contact
Contact 1 Name: Phone Number:
Contact 2 Name: Phone Number:
 
Allergy Information
Please provide any allergy or other medical information we should know about:

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Desired weeks of attendance
New this year: Camp extended to 4 weeks
Full Session: July 18 - August 12
  Need to miss last 2 days of camp (due to school), $50 off
Week 1: July 18 - July 22
Week 2: July 25 - July 29
Week 3: August 1 - August 5
Week 4: August 8 - August 12
  Need to miss last 2 days of week 4 (due to school), $50 off

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Early & After Care
Early care is available starting at 8:00am. After care is available until 5:30pm.
The cost is $5 per child per hour.
Early Care Time: Mon. Tues. Wed. Thurs. Fri.
After Care Time: Mon. Tues. Wed. Thurs. Fri.
Early & After Care Total (add to total payment): $

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Payment Information
Cost

$185 per week or $700 for full 4-week session

- A $50 non-refundable deposit is due at time of registration, per child (to be deducted from tuition).
- Sibling Discount: 5% off for each additional child.
Payment Options
1. One payment in the amount of $ to be paid on
2. Two payments in the amount of $ to be paid on $ & to be paid on
3. Deposit to charge now:

All payments are due before the first day of camp.
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Credit Card Type*

Credit Card Number*
CVV Code*
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Expiration Month*........Expiration Year*


To register by mail, please print this form and mail it with a $50 deposit to:

Chabad Jewish Community Center
1254 W. University Ave. #130
Flagstaff, AZ 86001
Release
As the parent(s) or legal guardian of the above child/ren, I/we authorize any adult acting on behalf of Camp Gan Israel to hospitalize or secure treatment for my/our child/ren, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit Camp Gan Israel personnel will try, but are not required, to communicate with me/us prior to such treatment.
I agree to the terms and conditions above.