Camp Gan Israel - 38th Year
Application Form - Winter Camp 
2009 / 2010 - 5770
Ilford Winter Day Camp

Monday 28th December 2009 - Friday 1st January 2010

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 (includes lunch each day)   

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  

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.