Registration

Camper and Family information
Child's Name*
First Name Last Name
Gender*

MaleFemale
Date of Birth*

Month Day Year
Nickname
Hebrew Name
Language Spoken at Home

Home Address

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

Hamptons Address*

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

Hamptons Phone Number*
Parents' Marital Status

MarriedSeparatedDivorced
Mom's Name*
First Name Last Name
Mom's Cell*
Mom's E-mail*
Dad's Name*
First Name Last Name
Dad's Cell*
Dad's E-mail*
Is your child currently attending school?

YesNo
Does your child receive any special services or have an IEP?
Does your child have any food allergies or medical issues we should be aware of? Please Describe
Is there any information regarding your child that you feel our camp should be aware of so that we can better care for him/her?
In one line, how would you describe your child?
Sibling(s)' name(s) and age(s)
Parental and Medical Consent/Financial Agreement
AUTHORIZED PICKUPS

Please list below caregivers who are authorized to pick up your child.
Full Name
First Name Last Name
Phone Number
E-mail
Full Name
First Name Last Name
Phone Number
E-mail
Full Name
First Name Last Name
Phone Number
E-mail
EMERGENCY INFORMATION

Please provide information for one person in the Hamptons, who we can contact in case

of emergency (if we can’t reach either parent). People listed as emergency contacts are

authorized to pick up your child.
Emergency Contact Name
First Name Last Name
Emergency Contact Phone Number
Relationship to camper
Sunscreen permission
During camp, the children will be spending lots of time outside. If you would like for us to apply sunscreen to your child, please check this box

I permit staff at Camp Mini Gan Israel to apply the provided sunscreen.
TERMS OF AGREEMENT

1. Full camp tuition is due upon registration

2. Due to the seasonal nature of summer camp and the set limitation of spaces offered, no refund shall be

provided for absences, changes, or withdrawals

3. Permission is granted for the camper to participate in all camp activities.

4. Permission is hereby granted for photographs to be taken of the camper and the camp has the right to utilize those photographs in camp brochures, on our website and in camp print and online advertising
MEDICAL PERMISSION STATEMENT

I hereby give Camp Gan Israel Southampton permission to take my child to any hospital facility or outside doctor when deemed necessary. Furthermore, I hereby give permission to such hospital or outside doctor to authorize x-rays and emergency treatment if deemed necessary. I understand that all medical bills for service rendered are my responsibility.
I have read the terms of agreement and the medical permission statement above and understand its terms and accept its conditions. In the event that this is executed by one parent, I acknowledge that I am also acting as the agent of the other parent with authority to enroll my child at Camp Gan Israel Southampton and to execute this agreement on his or her behalf. I recognize that the Camp relies upon the representation herein made in accepting this enrollment.
I have read the enrollment agreement and understand its’ terms and accept its’ conditions.
I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting "I agree" using any device, means, or action, I consent to the legally binding terms and conditions of this document.
I agree
Electronic Signature*
Today's Date

Month Day Year
Hour Minutes
Please note: a camp health form is required to be submitted online for each camper before the start of camp. You may submit the health form by clicking here.
Rates
● Early bird rates are available through March 1, 2025

● Full tuition is due upon registration

● Camp Tuition is refundable through April 30th, minus a $300 administrative fee for each registration. All registrations are final from May 1st.

● Campers in our First Summer group, (ages 12 - 24 months) must be registered for a

minimum of two weeks.

● Campers in our Goldfish group, (ages 2 -4 years old) must be registered for a minimum of

two consecutive weeks.
I am registering my child for...*

My First Summer GroupGoldfish Group
My First Summer Group*

Full Session (6 Weeks, June 30 - August 8)Week 1 (June 30- July 3)Week 2 (July 7 - July 11)Week 3 (July 14 - July 18)Week 4 (July 21 - July 25)Week 5 (July 28 - August 1)Week 6 (August 4- August 8)
Goldfish Group

Full Session (6 Weeks, June 30 - August 8)Week 1 (June 30- July 3)Week 2 (July 7 - July 11)Week 3 (July 14 - July 18)Week 4 (July 21 - July 25)Week 5 (July 28 - August 1)Week 6 (August 4- August 8)
How many weeks will you be registering for?*
How many weeks will you be registering for?*

Payment* *To pay via American Express please call Rabbi Rafe Konikov 631-287-2249 (To manually take the Amex card over the phone)

Credit Card

We accept Visa, MasterCard, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Total

$0.00
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Camper and Family information

Parental and Medical Consent/Financial Agreement

AUTHORIZED PICKUPS

EMERGENCY INFORMATION

TERMS OF AGREEMENT

MEDICAL PERMISSION STATEMENT

Rates