Child InformationChild's Name*First NameLast NameGender*SelectMaleFemaleBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearJewish BirthdayGrade Entering*T-shirt Size*SelectChild XSChild SChild MChild LChild XLAdult XSAdult SAdult MAdult LFamily InformationAddress*Street AddressStreet Address Line 2CityState / ProvincePostal / 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 SaharaYemenZambiaZimbabweOtherCountryPhone Number*Area CodePhone NumberE-mail*Parent # 1Parent # 1 Name*First NameLast NameParent # 1 Cell Number*Area CodePhone NumberParent # 1 E-mail*Parent # 2Parent # 2 NameFirst NameLast NameParent # 2 Cell NumberArea CodePhone NumberParent # 2 E-mailHealth InformationEmergency Contact Name*First NameLast NameRelationship*Emergency Contact Cell Number*Area CodePhone NumberPhysician or Medical Facility*Physician or Medical Facility Number*Area CodePhone NumberList 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?*SelectYesNoDoes your child have a history of*NonePhysical handicapsRheumatic feverHeart problemsSeizuresAsthmaDiabetesPlease 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 ChecklistSwimming 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 1Put whole face in waterSubmerge body under waterLevel 2Float independently on frontFloat independently on backSwim on front for 5 yds.Swim on back for 5 yds.Level 3Front crawl with rotary breathing for 10-15 yds.Back crawl for 10-15 yds.Elementary Backstroke kick for 10 yds.Level 4Front 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 5Front 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 6Front crawl for 100 yds.Back crawl for 100 yds.Breaststroke for 25 yds.Sidestroke for 25 yds.Butterfly for 10 yds. (arms & legs)Level 7500 yds. Continuous swim200 yds Front crawl100 yds. Back crawl50 yds Breaststroke50 yds. Sidestroke100 yds. Your choice Butterfly for 25 yds.Parental ConsentI hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately.*InitializeI 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*InitializeI 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.*InitializeI hereby authorize my child's photo to be used for marketing purposes*InitializeIn 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 NumberIf the above mentioned adult is not at home, follow these procedures*Camp OrderThe 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*No After CareWeek 1 (add me to waiting list)Week 2 (add me to waiting list)Week 3 (add me to waiting list)Week 4 (add me to waiting list)Week 5 (add me to waiting list)Transportation From Bellevue ($30 per week)*Not RequiredWeek 1 (add me to waiting list)Week 2 (add me to waiting list)Week 3 (add me to waiting list)Week 4 (add me to waiting list)Week 5 (add me to waiting list)Payment FormTotal$0.00Payment*Credit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2022202320242025202620272028202920302031Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / 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 SaharaYemenZambiaZimbabweOtherCountryGan Izzy Day Camp Terms & ConditionsI read and agree to the Gan Izzy Day Camp terms & conditions*YesNoSubmitShould be Empty: This page uses TLS encryption to keep your data secure.