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Please fill out the form below carefully. When you press submit, this form will be sent to our administration office. 

Family Information
Address
Street
City
State
Zip
Contact Info
Home Phone
Mother's Email
Father's Email
 
Child's Mother
Mother's Name
Hebrew Name
Work Phone Cell
Child's Father
Father's Name
Hebrew Name
Work Phone Cell
Emergency Contact Info
Name
Phone
Relationship  
Pediatrician
Name
Phone
   
No. of Children Registering
Camper 1 Information
Name
First
Preferred
Last
Age / Gender
Date of Birth
Age
Gender
Schools
School
Hebrew School
Entering Grade:
Select Division Camper 1
Tiny Tots (Girls and Boys 3-5)
Older Division (Girls entering grades 1-5, Boys entering grades 1-3)
Pioneer Program (Girls entering grades 6-8)    
Select Sessions Camper 1
Session 1: June 25 - June 29
Session 4: July 16 - 20
Session 2: July 2 - 6
Session 5: July 23 - 27
Session 3: July 9 - 13
Trip Camp: July 30 - August 3
Medical History Camper 1  
In the past six months, has your child had any serious illness?
No Yes. If yes, please list:
In the past six months, has your child been on any medications?
No  Yes. If yes, please list:
Does your child receive individualized assistance in school?
No Yes. If yes, please describe:
Triggers that may cause problems - Specify.
Signs and symptoms to watch for - Specify.
Steps the child care provider should follow.
Identify any child care staff to whom you have given specialized training/instruction to help treat symptoms.
When to call parents regarding symptoms or failure to respond to treatment.
When to consider that the condition requires emergency medical are or reassessment.
Additional information that may be helpful to the child care provider.
Check any applicable medical condition:
Asthma
Cerebral Palsy/motor disorder
Gastrointestinal or feeding concerns including special diet and supplements
Food allergies- Specify food(s): 

Non-food allergies - Specify: 
Diabetes
Epilepsy/seizure disorder
Any disorder including Cognitively Disables, LD, ADD, ADHA, or Autism
Other condition(s) requiring special care; please specify:
Camper 2 Information
Name
First
Preferred
Last
Age / Gender
Date of Birth
Age
Gender
Schools
School
Hebrew School
Entering Grade:
Select Division Camper 2
Tiny Tots (Girls and Boys 3-5)
Older Division (Girls entering grades 1-5, Boys entering grades 1-3)
Pioneer Program (Girls entering grades 6-8)    
Select Sessions Camper 2
Session 1: June 25 - June 29
Session 4: July 16 - 20
Session 2: July 2 - 6
Session 5: July 23 - 27
Session 3: July 9 - 13
Trip Camp: July 30 - August 3
Medical History Camper 2  
In the past six months, has your child had any serious illness?
No Yes. If yes, please list:
In the past six months, has your child been on any medications?
No  Yes. If yes, please list:
Does your child receive individualized assistance in school?
No Yes. If yes, please describe:
Triggers that may cause problems - Specify.
Signs and symptoms to watch for - Specify.
Steps the child care provider should follow.
Identify any child care staff to whom you have given specialized training/instruction to help treat symptoms.
When to call parents regarding symptoms or failure to respond to treatment.
When to consider that the condition requires emergency medical are or reassessment.
Additional information that may be helpful to the child care provider.
Check any applicable medical condition:
Asthma
Cerebral Palsy/motor disorder
Gastrointestinal or feeding concerns including special diet and supplements
Food allergies- Specify food(s): 

Non-food allergies - Specify: 
Diabetes
Epilepsy/seizure disorder
Any disorder including Cognitively Disables, LD, ADD, ADHA, or Autism
Other condition(s) requiring special care; please specify:
Camper 3 Information
Name
First
Preferred
Last
Age / Gender
Date of Birth
Age
Gender
Schools
School
Hebrew School
Entering Grade:
Select Division Camper 3
Tiny Tots (Girls and Boys 3-5)
Older Division (Girls entering grades 1-5, Boys entering grades 1-3)
Pioneer Program (Girls entering grades 6-8)    
Select Sessions Camper 3
Session 1: June 25 - June 29
Session 4: July 16 - 20
Session 2: July 2 - 6
Session 5: July 23 - 27
Session 3: July 9 - 13
Trip Camp: July 30 - August 3
Medical History Camper 3  
In the past six months, has your child had any serious illness?
No Yes. If yes, please list:
In the past six months, has your child been on any medications?
No  Yes. If yes, please list:
Does your child receive individualized assistance in school?
No Yes. If yes, please describe:
Triggers that may cause problems - Specify.
Signs and symptoms to watch for - Specify.
Steps the child care provider should follow.
Identify any child care staff to whom you have given specialized training/instruction to help treat symptoms.
When to call parents regarding symptoms or failure to respond to treatment.
When to consider that the condition requires emergency medical are or reassessment.
Additional information that may be helpful to the child care provider.
Check any applicable medical condition:
Asthma
Cerebral Palsy/motor disorder
Gastrointestinal or feeding concerns including special diet and supplements
Food allergies- Specify food(s): 

Non-food allergies - Specify: 
Diabetes
Epilepsy/seizure disorder
Any disorder including Cognitively Disables, LD, ADD, ADHA, or Autism
Other condition(s) requiring special care; please specify:
Extended Care | $5 per hour
AM Session: 8:00 - 10:00 am
PM Session: 4:00 - 6:00 pm
Days Needed |
Transportation

Please list anyone, other than yourself, who has permission to pick up your child from camp or from the bus stop: (Please note: Your child will not be released to anyone not on this list)

My child will need transportation from and back to Oak Park. The bus stop is located on Gardner St, between Victoria and Winchester.
My child will need transportation from Southfield and back to Oak Park. The Southfield stop is located at the Greyhound Station on Lahser. (On the way home the bus will only stop in Oak Park.)

Payment
Payment Method Total Amount to Charge $
Name on Card Card Number
Expiration CVV Code
Terms and Agreement
All forms and payment must be completed and submitted before your child begins camp.
Cost of Camp is $200 a week or $900 for five weeks.
Trip Camp is $240 for the week or $50 a day.
$8 extra charge for Thursday.
$50 Additional fee for Pioneer Program
Camp T-Shirt: $10
I hereby permit my child to participate in all activities at Ganeinu F.R.E.E. Camp– on site, off-site and trips. I permit Ganeinu to transport my child on camp-provided transportation and to obtain emergency medical care as the situation mandates. I release Ganeinu F.R.E.E. Camp and individuals from liability in case of accident during activities related to Ganeinu F.R.E.E. Camp, as long as normal safety procedures have been taken. I allow Ganeinu to photograph and/or videotape my child to be used on the website, video and any other Ganeinu related publications. I understand that my child may be dismissed during a camp day, due to illness or unacceptable behavior, at the discretion of the camp, and I agree to abide by the director’s decision. I understand that the tuition is non-refundable (but can be used as credit for future camp) and that refunds will not be made for incomplete attendance. In addition, I understand that submitting a registration form and payment does not guarantee me a spot in camp, and that acceptance into Ganeinu is at the discretion of the camp.
   
  By typing my name and the date below, I certify that the information on this application is true and correct and that I have read, and approve, the policies listed above.
Your Name: Date:

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Summer: 4230 Middlebelt Road • West Bloomfield, MI 48323 • 248-470-6881 Winter: 5595 W Maple Rd, West Bloomfield, MI 48322 • 248-470-6881
A branch of the world's largest Jewish Camping network, Camp Gan Israel International

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