Registration - JewishNaperville.com

Please fill out this form COMPLETELY and SIGN so that we can register your child(ren).

You will be charged a $75 down payment per child upon submission of this form. The remaining tuition balance will be charged to the card on file according to the payment option you choose.

PARENT INFORMATION

Full Name:*

First Name Last Name

Address:*

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

Cell Number:*

Area Code Phone Number

Work Number:

Area Code Phone Number

Home Number:*

Area Code Phone Number

E-mail:*

Is Parent Jewish:*

By birth Convert Neither

Full Name:*

First Name Last Name

Address Same as above:

Yes No

Address (If different than above):

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

Cell Number:*

Area Code Phone Number

Work Number:

Area Code Phone Number

Home Number:

Area Code Phone Number

E-mail:*

Is Parent Jewish*

By birth Convert Neither

Number of Children Registering:*

CAMPER INFORMATION

Camper 1:*

First Name Last Name

Camper 1 Hebrew Name

Gender:*

M F

Date of Birth:*

Month Day Year

Grade (Fall 2023):*

Age:*

School Attending (Fall 2023):*

Sessions:*

June 26 - 30 July 3 - 7 July 10 - 14

Division:*

Grand Gan Division - Ages 5-8 Pioneer Division - Ages 9-11

MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form for each child

In the past six months, has your child had any serious illnesses?*

No Yes

If yes, please list:

In the past six months, has your child been on any medications?*

No Yes

If yes, please list:

Does your child receive individualized assistance in school?*

No Yes

If yes, please list:

Does your child have any allergies or dietary restrictions?*

No Yes

If yes, please list:

**If you are only registering one camper, please skip to "Emergency Contact Information"**

Camper 2:

First Name Last Name

Camper 2 Hebrew Name:

Gender:

M F

Date of Birth:

Month Day Year

Grade (Fall 2023):

Age:

School Attending (Fall 2023):

Sessions:

June 26 - 30 July 3 - 7 July 10 - 14

Division:

Grand Gan Division - Ages 5-8 Pioneer Division - Ages 9-11

MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form for each child

In the past six months, has your child had any serious illnesses?

No Yes

If yes, please list:

In the past six months, has your child been on any medications?

No Yes

If yes, please list:

Does your child receive individualized assistance in school?

No Yes

If yes, please list:

Does your child have any allergies or dietary restrictions?

No Yes

If yes, please list:

Camper 3:

First Name Last Name

Camper 3 Hebrew Name:

Gender:

M F

Date of Birth:

Month Day Year

Grade (Fall 2023):

Age:

School Attending (Fall 2023):

Sessions:

June 26 - 30 July 3 - 7 July 10 - 14

Division:

Grand Gan Division - Ages 5-8 Pioneer Division - Ages 9-11

MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form for each child

In the past six months, has your child had any serious illnesses?

No Yes

If yes, please list:

In the past six months, has your child been on any medications?

No Yes

If yes, please list:

Does your child receive individualized assistance in school?

No Yes

If yes, please list:

Does your child have any allergies or dietary restrictions?

No Yes

If yes, please list:

EMERGENCY CONTACT INFORMATION
Please list at least one emergency contact other than the child's parents.

1. Emergency Contact Name [other than parents]:*

First Name Last Name

Relationship to Child:*

Address:*

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

Home Phone

Area Code Phone Number

Cell Phone*

Area Code Phone Number

2. Emergency Contact Name [other than parents]:

First Name Last Name

Relationship to Child:

Address:

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

Home Phone:

Area Code Phone Number

Cell Phone:

Area Code Phone Number

PHYSICIAN CONTACT INFORMATION

Name of Child's Physician or Medical Facility:*

Phone Number:*

Area Code Phone Number

Address:*

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

PAYMENT INFORMATION

DATES & RATES:

$275 per week, per child.

Additional 10% off early bird discount until Feb 6.

WEEK 1: June 26 - 30
WEEK 2: July 3 - July 7
WEEK 3: July 10 - 14

Registration is confirmed with a $75 down payment per child charged immediately upon submission of this form. Please indicate below when you would like us to charge the remaining tuition balance. It will be automatically charged to the card on file according to the payment option you choose.

Payment is needed in full before June 1. No tuition will be refunded due to absences.

Please select:*

Charge full amount on the following business day. Charge half on the following business day, half on June 1

I'd like to give the gift of camp to another Jewish child and donate to the camp scholarship fund

Total:

$0.00

Payment:

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

REGISTRATION POLICIES AND PARENTAL CONSENT

I hereby permit Camp Gan Israel to transport my child(ren) on camp provided transportation and to obtain emergency medical care as the situation mandates.

It is my responsibility to apply sunscreen on my child(ren) every morning before camp and to send along a labeled bottle for reapplication. However, in case of emergency, sunscreen is provided.

I am giving my permission for my child(ren) to participate in any pontoon/speed boating, horseback riding, ropes course, field trips, overnight trips and any other activity that is scheduled on the CGI calendar for his or her age group.

I allow Camp Gan Israel to photograph and/or videotape my child(ren) and to use these images for all promotional purposes.

The parent who signs this registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fees.

By typing my name and the date below, I certify that the information on this application is true and correct and that I have read, and approve, the policies listed above.

Full Name:*

First Name Last Name

Date:*

Month Day Year