Register On-line - Winter! | Camp Gan Israel

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	Summer Camp Gan Izzy 2011

Summer Camp 30th July - 17th August 2012 Book Early - Limited spaces

Camp Gan Israel - 40th Year
Application Form - Winter Camp
2011 - 5772
Ilford Winter Day Camp

Monday 26th December 2011 - Friday 30th December 2011

Junior Section only

Venue: Chabad Lubavitch Centre - 395 Eastern Avenue, Gants Hill

Age:      5-12 year olds.
Time:     Monday - Thursday 9.30am to 3.30pm
             Friday 9.30am to 12.30pm

Cost: £75.00 per child for the whole week or £16 per child for each day (includes lunch each day)

Please book my child in for the whole week at £75.00	Full Wk
Please book my child in for the following days at £16.00 per day	Mon	Tues	Wed	Thur	Fri

Part 1 - Family Details

(Please fill in a seperate form for each child)

Family Name
Childs First Name(s)
E-mail Address
Childs Hebrew Name		Male Female
Date of Birth		Age

Address
Post Code
Name of Day School
Hebrew Classes
Parents Names
Mother's Hebrew Name
Father's Hebrew Name
Synagogue Where Married
Current Synagogue Membership
Telephone: Home
Mobile
Business
Other
First Language
Other Languages Spoken at Home

Part 2 - Medical History

Family Doctor
Telephone Number
Address

Has your child been immunised against?

Diptheria	Yes No
Whooping Cough	Yes No
Tetanus	Yes No
Polio	Yes No
Measles	Yes No
HIB	Yes No

Does your child suffer from any allergies? Yes No
Please give details

Does your child suffer from any ongoing health problems? Yes No
Please give details

Has your child been in hospital lately? Yes No
Please give details

Does your child have any special dietary needs? Yes No
Please give details

Does your child have any special educational needs? Yes No
Please give details

Part 3 - Emergency Contacts

1st Person - Name
Relationship to child
Tel Home
Tel Mobile

2nd Person - Name
Relationship to child
Tel Home
Tel Mobile

3rd Person - Name
Relationship to child
Tel Home
Tel Mobile

We take photos of campers for the media, our website and Facebook. If you feel strongly against this please write to tell us.

I understand that in the event of an emergency the staff at Camp Gan Israel Ilford will contact me immediately. In the event that I, or my named emergency contact(s) cannot be reached, I understand that emergency treatment and / or advice will be saught for my child and I will be informed as soon as possible.

Please fill in your name and click the yes radial button to accept these terms:
I have read and accept the terms above No Yes

A member of staff at Chabad will contact you for details of how you would like to pay. Many thanks in advance.

Camp Gan Israel - N. E. London and Essex • 395 Eastern Avenue • Ilford, IG2 6LR • England • 44-20-8554-1624 - Charity Reg: 1123001
A branch of the world's largest Jewish Camping network, Camp Gan Israel International