Your Information Parent's Name* First Name Last Name Parent's E-mail* Camper's Name* First Name Last Name 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* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year 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. Submit Should be Empty: This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.