Camper's Name(s) Child 1* First Name Last Name Child 2 First Name Last Name Child 3 First Name Last Name Guardian Information Name:* First Name Last Name E-mail:* Cell phone:* Area Code Phone Number Home phone: Area Code Phone Number Home address: Street Address Subdivision City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Medical Information Physician's name:* Physician's phone number:* Area Code Phone Number Medical Insurer / Health Plan:* Policy / Group #* Emergency Contact Information In case of emergency, if parent or guardian cannot be reached, please contact: Contact 1 (name, phone & relationship):* Contact 2 (name, phone & relationship): Other than parents and emergency contacts, list any people authorized to pick-up students. (name and phone): PARENTAL RELEASE AND CONSENT. In case of an accident or serious illness involving my child whenever the child is in attendance at Camp Gan Israel, I request The Camp to telephone me at the above listed telephone. If in the judgment of The Camp, delay entailed in telephoning me or other persons named above would not be in the best interest of my child, I hereby authorize The Camp before telephoning me to take my child to any physician or surgeon selected by The Camp and licensed under the provision of the California Medical Practice Act, to any physician or surgeon selected by the director for such action as such physician or surgeon deems necessary or advisable in the circumstances. I hereby consent to any and all diagnostic procedures, examinations, care and treatment (including without limitation, X-ray examination, anesthetic and emergency surgical intervention) as any such physician or surgeon may deem necessary or advisable, whether such diagnostic procedure, examination, care or treatment is rendered at the office of such physician, surgeon or dentist or at a hospital or clinic. I understand that this authorization is given in advance of any specific diagnosis, examination, care or treatment being rendered and is given to provide authority and power on the part of any such physician or surgeon to render any and all such diagnostic procedures, examinations, care or treatment that he or she may deem necessary or advisable. I certify that no information concerning the health of this counselor/camper has been withheld or misrepresented. I authorize our physician to provide further medical history should it be deemed necessary. This completed form may be photocopied for trips out of camp. I hereby give permission, for my child registered in any of the Monday – Friday programs of Camp Gan Israel, to be taken by school bus on all outings and trips. I give permission to Camp Gan Israel to use camp photos of my child/ren in any camp publicity. Agreement* I Agree Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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