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Pioneers (Entering 5th - 8th) Registration

Parent information
Home Phone Number*
Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Info
Mother's Name*
First NameLast Name
Occupation*
Work Phone
Area CodePhone Number
Cell Phone*
Area CodePhone Number
E-mail*Primary email
Father's Info
Father's Name*
First NameLast Name
Occupation*
Work Phone
Area CodePhone Number
Cell Phone*
Area CodePhone Number
E-mail*
First Camper's Information
Child's Name*
First NameMiddle NameLast Name
Entering Grade*
Birth Date*
MonthDayYear
Gender*
MaleFemale
Is the child's father Jewish?*
YesNo
Is the child's mother Jewish?*
YesNo
Additional Camper Information
Does your child have any known allergies?*
YesNo
If yes, please specify
Does your child have an IEP or other special accommodations?*
YesNo
Group Placement: I would like my child placed with (must be entering the same grade)
Second Camper's Information:
Child's Name
First NameMiddle NameLast Name
Entering Grade
Birth Date
MonthDayYear
Gender
MaleFemale
Additional Camper Information
Does your child have any known allergies?
YesNo
If yes, please specify
Does your child have an IEP or other special accommodations?
YesNo
Group Placement: I would like my child placed with (must be entering the same grade)
Emergency Information
Emergency Contact 1
Emergency Contact 1*
First NameLast Name
Cell Number*
Area CodePhone Number
Work Number*
Area CodePhone Number
Relationship
Emergency Contact 2
Emergency Contact 2
First NameLast Name
Cell Number
Area CodePhone Number
Work Number
Area CodePhone Number
Relationship
Physician Information
Pediatrician/Physician Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Authorized people to pick up camper
Person 1*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship*
Person 2
First NameLast Name
Phone Number
Area CodePhone Number
Relationship
Person 3
First NameLast Name
Phone Number
Area CodePhone Number
Relationship
Swimming
Please describe your child's swimming ability.
Child 1 Swimming Ability*
Child 2 Swimming Ability
Extended Care
Early care will be available for $30 a session. Early care runs from 8:00 am - 9 am. Aftercare will be available for $30 a session. Aftercare runs from 4pm - 5:30pm. Sign up for both Earlycare and Aftercare for just $50 a session.
Child 1 - Earlycare needed for
Session 1Session 2Session 3Session 4
Child 1 - Aftercare needed for
Session 1Session 2Session 3Session 4
DISCOUNTED! Child 1 - Earlycare & Aftercare needed for
Session 1Session 2Session 3Session 4
Child 2 - Earlycare needed for
Session 1Session 2Session 3Session 4
Child 2 - Aftercare needed for
Session 1Session 2Session 3Session 4
DISCOUNTED! Child 2- Earlycare & Aftercare needed for
Session 1Session 2Session 3Session 4
Lunch
Lunches will be available for $25 a session. Please email for the menu.
Child 1 - Lunch
Session 1Session 2Session 3Session 4
Child 2 - Lunch
Session 1Session 2Session 3Session 4
T-Shirts
Please note, for safety of your child, we require that all campers & staff wear a Camp Gan Izzy t-shirt each trip day. While on field trips, camp shirts distinguish our campers and staff from other visitors.
T-shirts from previous years are sufficient.
Each t-shirt costs $10
Child 1 T-shirt size*
Number of T-shirts*
Child 2 T-shirt size
Number of T-shirts
Parental Involvement
Yes! I would like to get involved!
Bunk MotherCamp Committee
Does either parent have any special resources or skills to offer our campers or counselors?*
YesNo
If Yes, please specify
Permission
I hereby permit my child(ren) to participate in all activities at Camp Gan Izzy – on site, off-site and trips and be transported to and from the field trips and outings. I release Camp Gan Izzy of Colorado and individuals from liability in case of accident during activities related to Camp Gan Izzy of Colorado, as long as normal safety procedures have been taken. I understand that my child(ren) may be dismissed during a camp day, due to illness, at the discretion of the camp, and I agree to abide by the director’s decision. I am enclosing a minimum registration fee of $50.00 for each child. I understand that the fee is non-refundable.
I have read and agree*
YesNo
I give my child(ren) permission to participate in swimming as scheduled by Camp Gan Izzy of Colorado.*
YesNo
The parent who signs the registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fee.
Parent/Guardian*
First NameLast Name
Date*
MonthDayYear
Tuition Information
Pioneer Division - $250 per session
A $50 non-refundable registration fee per child applies as part of this registration.
Child 1- Tuition*
Session 1Session 2Session 3Session 4All Four Sessions
Child 2- Tuition
Session 1Session 2Session 3Session 4All Four Sessions
You may pay camp tuition in full now or else set up a payment plan with our office.Your child's registration fees are due in full by June 1st. The registration will not be complete until camp tuition and fees are paid in full.
Scholarships
Scholarships and payments plans are available. Please contact the office for more information.
Sponsor A Camper
Yes! I would like to enable a less fortunate child to enjoy a summer at Camp Gan Izzy.
I am enclosing
$200 for 1 week$400 for 2 weeks$800 for the whole summer
I would like to sponsor an alternate amount of:
$
Payment Information
You may pay camp tuition in full now or else set up a payment plan with our office.Your child's registration fees are due in full by June 1st. The registration will not be complete until camp tuition and fees are paid in full.
Total
$0.00

Payment

Credit Card Check

General comments
We are looking forward to a great summer!
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