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Winter Camp Registration

Winter Camp Registration

Winter Camp Registration form

Register Online

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us.

Please note that one registration form per child is needed.

Child Profile

Childs's First Name

Last

Hebrew Name

DOB

School

Grade

Dates Attending

Dec. 28 Dec. 29 Dec. 30 Dec. 31 Jan 1

Additional Child Profile

Childs's First Name

Last

Hebrew Name

DOB

School

Grade

Parent Information

Father's Name

Phone

Mother's Name

Phone

Is maternal mother Jewish

Address

City

State

Zip

Email Address

Emergency Information

Emergency Contact 1

Phone

Emergency Contact 2

Phone

CONFIDENTIAL: Does your child have any allergies, medical condition or other challenges we should be aware of?
If yes, please describe them and indicate special precautions or care needed.

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Camp Gan Israel to hospitalize or secure treatment for my/our child, 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 also give permission for my/our child to be in photos taken during camp activities and may be used in camp marketing and publicity.

Method of Payment:

Please make checks payable to:
Chabad House 2352 Albany Avenue
West Hartford CT 06117

Will send Check or Cash Credit

Credit Card Info:

First Name:

Last Name:

Address:

City, State and Zip:

Card Type

Credit Card Number:

Exp. Date:

(mm/yyyy)

Security Code:

(Last 3 digits on back of card)

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