Junior Counselor Registration Form
Camp Gan Israel 2019
|
A limited number of just 5 Junior Counselors (from ages 13 - 17) per week will be accepted for this summer, and it will run on a first-come first-serve basis. Please choose which weeks you would prefer to join camp and we will let you know if those weeks are available.
Part one: Junior Counselor Information
First Name: Last Name:
Home Address: City: Zip:
Home Phone: T-Shirt Size
S Med Large
Birthdate: Age: Gender: Jewish Name
Part two: Parents Information
Father's Name: Father's Cell Phone: Father's E-mail:
Mother's Name: Mother's Cell Phone: Mother's E-mail
Part three: Please select which week you will be attending camp:
Part four: Please let us know if you will be using the Lunch Program Menu.
Note: Please advise us if you have any food allergies and/or must adhere to a special diet.
Part five: Medical Information (confidential) - For parents to fill out
In case of emergency, please: |
In the event of an emergency when a parent/guardian is unavailable, I hereby authorize a representative of Camp Gan Israel to make such arrangements as considered necessary for my child to receive medical or hospital care, including transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment as considered necessary. In the event such physician is not available, I authorize such care and treatment to be performed by any licensed physician or surgeon. |
I do not choose the option on the left, please take the following action:
|
In case of emergency, and a parent can not be reached, please contact:
|
Emergency Contact #1
Name:
Phone:
|
Emergency Contact #2
Name:
Phone:
|
Please tell us about your child:
|
1. Does your child have any severe medical problems that we should know about (for example: asthma, allergies to food, allergies to drugs, hearing trouble, epilepsy, diabetes, physical disabilities etc)? Please specify: |
2. Can your child swim? |
3. Is your child taking medications at this time? If so, please specify. |
4. What is the name of your primary doctor? |
5. What is the phone number to your primary doctor? |
Part six: Camp Consent & Trip Release Form - For parents to fill out
Comments/Questions:
Thank you very much! We are looking forward to a great summer together at CGI!