Please note: Registration is pending approval from camp Parent information Home Phone Number* Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Mother's Info Mother's Name* First Name Last Name Cell Phone* Area Code Phone Number E-mail* Primary email Father's Info Father's Name* First Name Last Name Cell Phone* Area Code Phone Number E-mail* First Camper's Information Child's Name* First Name Middle Name Last Name Entering Grade* Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Gender* MaleFemale Name of school* 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 Will your child come to camp with any medications* YesNo If yes, please specify Does your child have an IEP or other special accommodations?* YesNo If yes, please specify Group Placement: I would like my child placed with (must be entering the same grade) Second Camper's Information: Child's Name First Name Middle Name Last Name Entering Grade Birth Date 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Gender MaleFemale Name of school Additional Camper Information Does your child have any known allergies? YesNo If yes, please specify Will your child come to camp with any medications YesNo If yes, please specify Does your child have an IEP or other special accommodations? YesNo If yes, please specify Group Placement: I would like my child placed with (must be entering the same grade) Emergency Information Emergency Contact 1In the unlikely event of an emergency, we will first reach out to our camper's parents. Please fill out the emergency contact for us to contact if the parents are unavailable. Emergency Contact 1* First Name Last Name Cell Number* Area Code Phone Number Relationship* Authorized people to pick up camperIf someone OTHER than a camper's parent will be picking them up from camp, they need to be authorized below, for the camper to be permitted to go with them. Person 1 First Name Last Name Phone Number Area Code Phone Number Relationship Person 2 First Name Last Name Phone Number Area Code Phone Number Relationship Permission I hereby permit my child(ren) to participate in all activities at Camp Gan Izzy Winter Camp – on site, off-site and trips and be transported to and from the field trips and outings. I release Camp Gan Izzy Winter Camp of Colorado and individuals from liability in case of accident during activities related to Camp Gan Izzy Winter Camp, 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 have read and agree* Yes 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 Name Last Name Date* Month Day Year Tuition Information$250 per session Child 1- Tuition* Sign me up! Child 2- Tuition Sign me up! Scholarships Scholarships and payments plans are available. Please contact the office for more information. Sponsor A CamperYes! I would like to enable a less fortunate child to enjoy winter break at Camp Gan Izzy. $250 for the week I would like to sponsor an alternate amount of: $ Payment Information Total $0.00 Pay in full now via credit card or with a payment plan Credit Card Payment plan Credit Card We accept Visa, MasterCard, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2023202420252026202720282029203020312032 Expiration YearPlease have the office contact me to set up a monthly payment plan. Referred by/comments We are looking forward to a great winter! 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