Printed fromChabadNashville.com

ב"ה

ARCHIVE CAMP GAN IZZY

2017 Camp Registration

We're Glad You're Here!
Thank you for joining theCamp Gan Izzy Family!

We are looking forward to a great summer and are glad you'll be a part of it!

A few notes about registering your Camper(s). We have tried to make the registration form as quick and easy to fill out as possible while gathering all the information we need to keep your child safe and well cared for. If at any time you have a question or get stuck, please call us at 615-646-5750 and we will walk you through.

If you're registering more than one Camper, we have tried to cut down on asking you multiple times for information that is likely the same for all your children. While you'll have to fill out a registration form and pay for each child separately, you will see a spot to let us know you are registering several Camper's and we will combine the information to make a complete record for each Camper.
Family Contact Information
Parent's Name

First Name Last Name

Address

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

Mom's Cell

Area Code Phone Number
Dad's Cell

Area Code Phone Number
Best email for daily updates and reminders
Emergency Contact

First Name Last Name
Emergency Contact

Area Code Phone Number
Relationship to Camper
Are you registering siblings:*

Yes No. Please skip down to Camper Information
If need be, are you available on either Tuesday and Thursday to help with driving to an activity?

No Tuesday Thursday
If you are, we realize that some basic information is true for every child in your family. While you’ll need to fill out a separate registration for each child, we have taken the liberty of guessing that the information above may be the same for all your children. If it is, simply check the box below and our office will combine the records so that each child’s registration is complete without you having to fill out duplicate information. If there are minor differences, please note below.
If so, do they all share the same information as above?

Yes No. Please list the differences below
Please tell us which child has what difference.
Camper Information
Camper's Name*

First Name Last Name
Any special information you'd like us to know regarding the sessions?
Does Camper need Early care from 8:30 - 9:30? Cost is $15 per morning*

No If so, what days? Monday? Tuesday? Wednesday? Thursday? Friday?
Birthday of Camper*

Month Day Year
Age of Camper*
If Camper is 13 - 14, does she want to be a Counselor in Training?*

Yes No NA
T-Shirt Size*

Child Extra Small/Small Child Medium Adult Small Adult Medium Adult Large/XL
Please tell us your camper's favorite sandwich*
Please tell us her second favorite sandwich
Medical Information
Your son/daughter is below legal age of consent (21 years old). The law requires that we have your permission if medical service should be needed. Your signature on the consent form will authorize us to proceed with the care of lesser types of medical problems, which may occur. In the event of any major health problems, we will notify you as promptly as possible and follow your instructions. If we are unable to contact you or your alternative listed below, your child will be taken to the nearest Emergency Room facility and will be treated there.
Does your child have any medical conditions that we should know about?
Medical conditions?*

No Yes, please describe below:
Check which conditions apply

Asthma Peanut allergy Tree nut allergy Drug allergies Other, please describe below
Please list any other medical conditions your child has
Any limits to your child's physical activities?*

No Yes, please describe below:
Please describe physical limitations
Has your child had any serious illness in the past three years?*

No If so, please describe below
Please describe serious illness
At the present time, is your child under doctor’s care?*

No Yes, please describe below
Please describe care
Can your child swim unassisted for the length of a pool?*

Yes No
Is your child taking any medication at this time?*

No Yes. All medicine must be brought to camp in it's original container
Doctor Name
Doctor Phone
Medical Insurance Carrier
Medical Insurance ID #, Group #, etc
Trip Release Form
In the unlikely event your child needs emergency medical care, we want to know what course of action you'd like us to take. Please indicate your choice of OPTION #1 or #2 below.
OPTION #1 In the event of an emergency when a parent/guardian is unavailable, I hereby authorize a representative of the Center for Jewish Awareness 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 above 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.
OPTION #2 I do not choose the above; I desire the following action to be taken in the event of an emergency.
OPTION #2, Cont. Please list the course of action to be followed in the event of an emergency.
Which course of action are you authorizing Chabad of Nashville to take in the case of an ermergency?*

OPTION #1 OPTION #2
By typing in your name below, you agree to bear all costs as a result of the foregoing and that you agree to allow your child on all off-campus activities and trips.
Parent's Name*
Camp Fees
Number of days you are coming to Camp
What days are you coming to Camp?

Monday Tuesday Wednesday Thursday Friday
Number of days you need Early Care?
Are registering a 13 or 14 year old as a CIT?
Camp t-shirts are to be worn on Tuesday and Thursdays for outings. How many t-shirts would you like? They are $10 each
Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

Should be Empty:

This page uses TLS encryption to keep your data secure.