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:

Week 1 June 24 - June 28

Week 2 July 1  - July 5 (No camp Wednesday July 4th)

Week 3 July 8 - July 12

Week 4 July 15 - July 19

Week 5 July 22 - July 26

Week 6 July 29- Aug 2

Week 7 Aug 5 - Aug 9

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

   I permit my child to participate in all activities of Camp Gan Israel, on site, off site and trips.
   I understand that my child 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 permit my child’s photo to be used on our Camp Website or e-mail newsletters.

Parent "Signature"  

Date:                     

  Comments/Questions:

Thank you very much! We are looking forward to a great summer together at CGI!