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Camper Information:

First Name: Last Name: Hebrew Name:

Birthdate: Current Age: Hebrew Birthdate (if known):

Current School: Grade for 2017-2018:

Please Select A T-Shirt Size:

Youth Extra Small (size 4)

Youth Small (size 6-8)

Youth Medium (size 10-12)

Youth Large (size 14-16)

Adult Small

Please list any allergies or medical information that needs to be shared about your child:

Family Information:

Home Address: City/State/Zip:

Mother's First Name: Mother's Last Name:

Mother's Hebrew Name:

Father's First Name: Father's Last Name:

Father's Hebrew Name:

Contact and Emergency Information:

Email Address For Camp Related Information:

Home Phone Number:

Mother's Cell Phone Number: Mother's Work Number:

Father's Cell Phone Number: Father's Work Number:

Emergency Contact: Relationship to Camper:

Phone Number For Emergency Contact:

Please indicate who we should call first if we need to reach you:

Enrollment Information:

Please indicate which sessions your child will be attending:

Session 1 (July 10- July 14)

Session 2 (July 17 - July 21)

Payment Information:

I will pay online wit a credit card

I will mail a check to 1920 Colley Avenue, Norfolk, VA 23517

Credit Card Information:

Name as it appears on card:

Billing zip code for card: Type of Card:

Card Number: Expiration: CV Code:

I authorize Chabad of Tidewater to charge my card in the amount of .

Thank you for enrolling in Camp Gan Israel - we can't wait to see you in camp!

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Camp Gan Israel 1920 Colley Ave Norfolk, VA 23517 757-616-0770
A branch of the world's largest Jewish Camping network, Camp Gan Israel International

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