Gan Izzy Winter Day Camp Registration Form

Scroll down to register!
Please fill out the form below carefully. When you press submit, this form will be sent to our administration office.

Note: Please use a separate form for each child.
Camper/Parent Information
Full Name*

First Name Last Name
Gender*

Female Male

Address*

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

Phone Number*

Area Code Phone Number
Birth Date*

Month Day Year
School*
Grade*
Mother's Name

First Name Last Name
Mother's E-mail
Mother's Cell Phone Number

Area Code Phone Number
Mother's Work Phone Number

Area Code Phone Number
Father's Name

First Name Last Name
Father's E-mail
Father's Cell Phone Number

Area Code Phone Number
Father's Work Phone Number

Area Code Phone Number
Emergency Contact Name

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
Relationship to Camper*
Pediatrician Name*

First Name Last Name
Pediatrician Phone Number*

Area Code Phone Number
Pediatrician E-mail
Allergies?*

Yes No
Please indicate number of days your child will attend camp:
Attending:* Prices after Dec 4: $50 per day OR $170 for all 4 Days

Full program - December 24, December 26-28 - $170 December 24 - Altitude Trampoline Park - $50 December 26 - Pump it Up - $50 December 27 - Funplex - $50 December 28 - Shabbat Day with Challah Baking and more! - $50
Attending:

Full Program - $90 through 12/11 Only (Normally $130) Tuesday 12/26 - Field trip to The Franklin Institute - $35 through 12/11 Only (Normally $50) Wednesday 12/27 - Field trip to Altitude Trampoline Park - $35 through 12/11 Only (Normally $50) Thursday 12/28 - Field trip to Funplex - $35 through 12/11 Only (Normally $50)
Early Drop off (8 AM - $7 per day)

Monday Wednesday Thursday Friday
Late Pick up (4:30 PM - $7 per day)

Monday Wednesday Thursday Friday
Late Pick up (5:30 PM - $12 per day)

Monday Wednesday Thursday Friday
To Apply for a Winter Camp Scholarship, please CLICK HERE.
Important
Must be paid in full in order to reserve a spot for your child.
Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

I give my child permission to attend all trips, participate in all on-site activities and receive medical care in the case of emergency. Participation in Gan Izzy sponsored activities constitutes permission to use photos of participants for promotional purposes. I also agree not to sue Chabad of DE, Camp Gan Izzy or any of its employees for any damage, claim or injury that my child may sustain, arising from or relating to any activity or camp experience.
Date of Application
Should be Empty:

Camper/Parent Information

Please indicate number of days your child will attend camp:

Important