Child Information |
First Name
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Gender
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Division Attending:
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Weeks Attending $290 Per week (Security Included)
Week 1: June 29 - July 3 Week 2: July 6 - July 10 Week 3: July 13 - July 17 Week 4: July 20 - July 24 Week 5: July 27 - July 31 (No Camp on Thursday) Week 6: August 3 - August 7 Week 7: August 10 - August 14 Week 8: August 17 - August 21 |
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After Care | $30 per week | 3:45-4:45pm
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**After Care at Issaquah location only |
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Family Information |
Address
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City
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Zip
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Home Phone
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Email
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Parent # 1 |
Name
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Work Phone
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Cell
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Email Address
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Parent # 2 |
Name
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Work Phone
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Cell
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Email Address
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Health & Transportation |
Emergency Contact Information |
Emergency Contact Name
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Relationship
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Address
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Home Phone
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Work/Mobile Phone
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Additional Persons Authorized to Care for Child |
Relationship
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Address
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Home Phone
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Work/Mobile Phone
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Physician or Medical Facility
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Phone
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Parental Consent and Transportation Information |
I hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately. |
Initialize
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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 |
Initialize
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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. |
Initialize
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I hereby authorize my child's photo to be used for marketing purposes |
Initialize
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In the event that I am not at drop off the driver is authorized to leave my children with:
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Phone
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If the above mentioned adult is not at home, follow these procedures
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Health History and Special Instructions |
List any illnesses your child had within past 6 months
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List any Sensitivities your child has. Any dislikes you feel we should be aware of?
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Does your child have any allergies?
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Does your child have a history of |
Physical handicaps Rheumatic fever Heart problems Seizures Asthma Diabetes Other (describe) |
Please describe any instructions that would be helpful in caring or for your child, or special medical information needed by the child’s care staff/provider. |
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Swimming Checklist |
Swimming Level Presently
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Swimming Level Last Completed & When
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The checklist below is a list of skills required for each swimming level. These skills correspond to the American Red Cross Swimming Program. For each level, please check the skills your child has. This checklist will help us to place your child in the most appropriate level. |
Level 1
Put whole face in water Submerge body under water |
Level 2
Float independently on front Float independently on back Swim on front for 5 yds. Swim on back for 5 yds. |
Level 3
Front crawl with rotary breathing for 10-15 yds. Back crawl for 10-15 yds. Elementary Backstroke kick for 10 yds. |
Level 4
Front crawl for 25 yds. Back crawl for 25 yds. Sidestroke kick for 10 yds. Breaststroke kick for 10 yds. Elementary Backstroke for 10 yds. (arms & legs) |
Level 5
Front crawl for 50 yds. Back crawl for 50 yds. Breaststroke for 10 yds. (arms & legs) Elementary Backstroke for 25 yds. Sidestroke for 10 yds (arms & legs) Dolphin kick for 10 yds. |
Level 6
Front crawl for 100 yds. Back crawl for 100 yds. Breaststroke for 25 yds. Sidestroke for 25 yds. Butterfly for 10 yds. (arms & legs) |
Level 7
500 yds. Continuous swim 200 yds Front crawl 100 yds. Back crawl 50 yds Breaststroke 50 yds. Sidestroke 100 yds. Your choice Butterfly for 25 yds. |
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Camp T-shirt |
T-shirt Size
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Transportation Information |
Transportation
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Registration Fee |
I authorize Camp Gan Israel to charge my card non-refundable registration fees in the amount of $100.00
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Please charge my total price on my Credit Card (Additional 3% Convenience Fee will be added) |
I will pay by Check/Cash |
Name on Card
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Card Number
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Expiration
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CVV Security Code
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Comments
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