Child Information
First Name
Division Attending:

After Care | $30 per week | 3:45-4:45pm
Family Information
Health & Transportation
Emergency Contact Information
Additional Persons Authorized to Care for Child Relationship
Home Phone
Work/Mobile Phone
Physician or Medical Facility
Parental Consent and Transportation Information
I hereby give my consent for emergency medical treatment, to be used only if I cannot be reached immediately. Initialize
I 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 Initialize
I 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. Initialize
I hereby authorize my child's photo to be used for marketing purposes Initialize
In the event that I am not at drop off the driver is authorized to leave my children with:
If the above mentioned adult is not at home, follow these procedures
Health History and Special Instructions
List 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?
Does your child have a history of
Physical handicaps Rheumatic fever Heart problems Seizures Asthma Diabetes Other (describe)
Please 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 Checklist
Swimming Level Presently
Swimming Level Last Completed & When
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 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
Camp T-shirt
Transportation Information
Registration Fee
I authorize Camp Gan Israel to charge my card non-refundable registration fees in the amount of $55.00