Registration - ChabadIssaquah.com

Child Information

Child's Name*

First NameLast Name

Gender*

Birth Date*

MonthDayYear

Jewish Birthday

Grade Entering*

T-shirt Size*

Family Information

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*

Area CodePhone Number

E-mail*

Parent # 1

Parent # 1 Name*

First NameLast Name

Parent # 1 Cell Number*

Area CodePhone Number

Parent # 1 E-mail*

Parent # 2

Parent # 2 Name

First NameLast Name

Parent # 2 Cell Number

Area CodePhone Number

Parent # 2 E-mail

Health Information

Emergency Contact Name*

First NameLast Name

Relationship*

Emergency Contact Cell Number*

Area CodePhone Number

Physician or Medical Facility*

Physician or Medical Facility Number*

Area CodePhone Number

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*

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*

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 waterSubmerge body under water

Level 2

Float independently on frontFloat independently on backSwim 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

Level 5

Level 6

Level 7

Parental Consent

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 Number For Alternative Drop-off*

Area CodePhone Number

If the above mentioned adult is not at home, follow these procedures*

Camp Order

The early bird price for camp is $325 per week. Price will go up to $375 per week April 1st.(Security Included)

Weeks Attending*

Week 1: June 27 - July 1st (add me to waiting list)Week 2: July 4th - July 8th (add me to waiting list)Week 3: July 11th - July 15th (add me to waiting list)Week 4: July 18th - July 22nd (add me to waiting list)Week 5: July 25th - July 29th (add me to waiting list)

We are currently full for ALL weeks, but no worries, you will be placed on our waiting list. You will not be charged for the weeks you selected. Please be in contact with the office at Chabad 425-427-1654. Thank you.

After Care | $40 per week | 3:45-4:45pm. **After Care at Issaquah location only*

Transportation From Bellevue ($30 per week)*

Payment Form

Total

$0.00

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Gan Izzy Day Camp Terms & Conditions

I read and agree to the Gan Izzy Day Camp terms & conditions*

YesNo