Please fill out this COMPLETELY and SIGN so that we can register your child(ren). Click here for print version.

Emergency Form Parent Handbook

PARENT INFORMATION

  Mother's Name
  Address City/State/Zip
  Cell Phone Home Phone
  Work Phone Email Address
  Father's Name Same address
  Address City/State/Zip
  Cell Phone Home Phone
  Work Phone Email Address

 

1. Camper's Name: [Last, First]

  Gender & DOB: M F
  Grade [Fall 2017]: School Attending [Fall 2017]:
  Sessions:
MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form foreach child.
  In the past six months, has your child had any serious illnesses?
No Yes. If yes, please list:
  In the past six months, has your child been on any medications?
No Yes. If yes, please list:
  Does your child receive individualized assistance in school?
No Yes. If yes, please describe:

**If you are only registering one camper, please skip to "Emergency Contact Information"**

2. Camper's Name: [Last, First]

  Gender & DOB: M F
  Grade [Fall 2017]: School Attending [Fall 2017]:
  Sessions:
MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form foreach child.
  In the past six months, has your child had any serious illnesses?
No Yes. If yes, please list:
  In the past six months, has your child been on any medications?
No Yes. If yes, please list:
  Does your child receive individualized assistance in school?
No Yes. If yes, please describe:

 

3. Camper's Name:[Last, First]

  Gender & DOB: M F
  Grade [Fall 2017]: School Attending [Fall 2017]:
  Sessions:
MEDICAL HISTORY
Please note: you must also fill out a Medical History and Emergency Care form foreach child.
  In the past six months, has your child had any serious illnesses?
No Yes. If yes, please list:
  In the past six months, has your child been on any medications?
No Yes. If yes, please list:
  Does your child receive individualized assistance in school?
No Yes. If yes, please describe:

 

EMERGENCY CONTACT INFORMATION

Please list at least one emergency contact other than the child's parents.

1. Emergency Contact Name [other than parents]
  Relationship to Child
  Address City/State/Zip
  Home Phone Other Phone
2. Emergency Contact Name [other than parents]
  Relationship to Child
  Address City/State/Zip
  Home Phone Other Phone
 

Physician Contact Information

  Name of Child's Physician or Medical Facility
  Phone Address

 

Payment Information
 

DATES & RATES:

$225 per week
WEEK 1: June 12–16
WEEK 2: June 19–23

$10 tshirt fee

$25 lunch fee per week

I will pay by:

Check - mail to:
Chabad of Waukesha 1222 East Broadway, Waukesha, WI 53186

Credit Card - complete information below

Scholarship Fund- Contact Camp@JewishWaukesha.cm

  Name on Card
  Total Deposit Amount
  Credit Card #
  Card Type/Exp. Date
  CCV Number

 

REGISTRATION POLICIES AND PARENTAL CONSENT

 

I hereby permit Camp Gan Israel to transport my child(ren) on camp provided transportation and to obtain emergency medical care as the situation mandates.

It is my responsibility to apply sunscreen on my child(ren) every morning before camp and to send along a labeled bottle for reapplication. However, in case of emergency, Rocky Mountain SPF 30 sunscreen is provided.

I am giving my permission for my child(ren) to participate in any pontoon/speed boating, horseback riding, ropes course, field trips, overnight trips and any other activity that is scheduled on the CGI calendar for his or her age group.

I allow Camp Gan Israel to photograph and/or videotape my child(ren) and to use these images for all promotional purposes.

The parent who signs this registration form represents that he/she has full authority to do so and will be responsible for payment of the camp fees.

  By typing my name and the date below, I certify that the information on this application is true and correct and that I have read, and approve, the policies listed above.
  Your Name: Date: