Child Information
Child's First Name
Child's Last Name
Gender
- Select -
Male
Female
Date Of Birth
Jewish Birthday
Currently my child is in grade:
- Select -
K
1
2
3
4
5
In Fall of 2025 my child will enter:
- Select -
K
1
2
3
4
5
6
T-shirt Size
- Select -
Child XS
Child S
Child M
Child L
Child XL
Adult XS
Adult S
Adult M
Adult L
Does your child have an IEP (Individual Education Plan) or a 504 at school?
-Select-
Yes
No
If you answered yes to the above question, please elaborate
Bunk request for a friend (DISCLAIMER: Please be sure the friend requests your child as well to ensure that they will be paired. Any other request cannot be guaranteed)
Friend Name #1
Celebrating birthday over the duration of the camp days attending
Yes
No
Parent # 1 Information
First Name
Last Name
Phone
Email
Parent 1 Born Jewish
-Select-
Yes
Converted
Not Jewish
Converted by Whom:
Parent # 2 Information
First Name
Last Name
Phone
Email
Parent 2 Born Jewish
-Select-
Yes
Converted
Not Jewish
Converted By Whom:
Address
Address
City
State
Zip
Health Information
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Cell Phone
Physician or Medical Facility
List any illnesses your child had within past 6 months
List any sensitivities your child has. Any dislikes you feel we should be aware of?
Does your child have any allergies?
- Select -
Yes
No
Please add any allergy information or general instructions that would be helpful in caring for your child, or special medical information needed by the child’s care staff/provider.
Does your child have a history of: Heart problems, Physical handicaps, Rheumatic fever, Heart problems, Seizures, Asthma, Diabetes, Other Medical history? If so, please describe. If none, please leave blank or write 'none.'
In case my child is stung by wasps, I authorize camp to immediately administer:
Oral Benadryl
Cream Benadryl
I authorize camp to administer if needed the following over the counter medication:
Tylenol
Ibuprofen
Swimming Checklist
This checklist has been modeled after the American Red Cross Swimming Program. We do our swimming at the public area on the lake. Your response, plus a test on-site by our lifeguard, will determine if your child can swim without a life jacket.
Parental Consent
I hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately.
I hereby give permission for my child to be transported and participate in field trips during operating hours. Details will be sent to me in advance
I hereby authorize Camp Gan Israel to transport my child between the central pickup point and the camp location, Eastside Torah Center and Chabad of the Central Cascades.
I hereby authorize my child's photo to be used for marketing purposes
Who to call if parent does not arrive during the pickup window
Phone Number
Camp Weeks Attending
Please add any special requests for after care/bus transportation:
Credit Card Information
Type
Visa
MC
Amex
Discover
Number
Expiration
Code
Use contact info above
Name
Address
Zip
Gan Izzy Day camp
Terms and conditions
I read and agree to the Gan Izzy Day Camp terms & conditions
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