Registration - Chabad of the Central Cascades

Swimming Checklist

Swimming Level Presently

Swimming Level Last Completed & When

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.

Child Information
First Name	Last Name	Gender
Date of Birth	Jewish Birthday	Grade Entering
School	Division Attending: Weeks 2 3 4 and 4 are Full - Ask to be placed on a waiting list Gani Preschool (3 years - entering K) Gan Izzy Day Camp (Grades K-6)
Weeks Attending ($210 per week) \| Week 1: July 2 - 6
Weeks Attending ($225 per week) Week 1: July 2 - 6 Week 4: July 23 - 27 Week 5: July 30 - August 2 Week 6: August 6 - 10 Week 7: August 13 - 17 Week 8: August 20 - 24
After Care \| $30 per week \| 3:45-4:45pm

Family Information
Address	City	Zip
Home Phone	Email
Father
Name	Work Phone	Cell
Email Address
Mother
Name	Work Phone	Cell
Email Address

Health & Transportation
Emergency Contact Information
Emergency Contact Name	Relationship	Address
Home Phone	Work/Mobile Phone
Additional Persons Authorized to Care for Child	Relationship	Address
Home Phone	Work/Mobile Phone
Physician or Medical Facility	Phone

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
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
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
I hereby authorize my child's photo to be used for marketing purposes		Initialize
In the event that I am not at drop off the driver is authorized to leave my children with:		Phone
If the above mentioned adult is not at home, follow these procedures

Health History and Special Instructions
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?
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.

Swimming Checklist
Swimming Level Presently	Swimming Level Last Completed & When
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.

Camp T-shirt
T-shirt Size

Transportation Information
Transportation


Registration Fee
I authorize Camp Gan Israel to charge my card non-refundable registration fees in the amount of $55.00
Name on Card	Card Number	Expiration
CVV Security Code	Comments