Winter Camp Registration 2013 Please fill out a seperate registration form for each child! Please email [email protected] to request a scholarship. Parent's Information Mother's Name Father's Name Address 1 Address 2 City State/Zip Home phone E-mail Mother's Cell Father's Cell Mother's Work Father's Work Camper's Information Name Hebrew name Date of birth Age Grade Previous Hebrew Education My child will attend: Full Week Individual Days Mon. 12/23 Tue. 12/24 Wed. 12/25 Thur. 12/26 Fri. 12/27 Any medical or other information regarding your child we should be aware of: Emergency Contact Name Relationship Phone Name Relationship Phone I herby permit my child to participate in all CGI activities. I also permit my child to join all trips beyond the program property. In case of emergency I hereby authorize the CGI Program to have my child taken care of by a physician in any way the situation may call for. Camp T-shirt ($5 online, $10 at camp) - Size: XS S M L XL Quantity: Payment Information Payment Info: $35 per day, or $150 for full week Payment Method CC check/other Total $ Card Type Please Select Visa Mastercard American Express Card Number Expiration Date CVV Billing Address: IF DIFFERENT FROM ADDRESS ABOVE Address Address 2 City/State/Zip Comments This page uses 128 bit SSL encryption to keep your data secure.
