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Ganeinu F.R.E.E. Camp Registration Form 

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

Please note that one registration form is required per camper.

Camper/Parent Information
Child's Name
 

First
 

Last

M
 F
 
    Middle 
Preferred Name
   
Address
  Street
City
State
Zip
Date of Birth
  Age on first day of camp 
         
Schools
  School
Hebrew School Entering Grade:
Child's Mother
  Mother's Name

Hebrew Name 
Work Phone

Cell Phone
Email Address
 
Child's Father
 

Father's Name

Hebrew Name

Work Phone 
Cell Phone
 Email Address
 
Emergency Contact
  Name
Phone
Relationship
Pediatrician
  Name
Phone
   
 
 

Medical History

1.

In the past six months, has your child had any serious illness?
No Yes. If yes, please list: 

2.

In the past six months, has your child been on any medications?
No Yes. If yes, please list: 

3.

Does your child receive individualized assistance in school?
No Yes. If yes, please describe: 

4.

Check any special medical condition that your child may have:

 

No specific 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:

 

5.

Triggers that may cause problems - Specify.

6.

Signs and symptoms to watch for - Specify.

7.

Steps the child care provider should follow.

8.

Identify any child care staff to whom you have given specialized training/instruction to help treat symptoms.

9.

When to call parents regarding symptoms or failure to respond to treatment.

10.

When to consider that the condition requires emergency medical are or reassessment.

11.

Additional information that may be helpful to the child care provider.

 

My Child will Attend:
 

Camp Dates: June 26 - July 28 Trip Camp: July 31 - August 4 


Tiny Tots Division: (Girls & Boys ages 3-6)
Week 1 (June 26-30)Week 2 (July 3 -7)Week 3 (July 10-14)
Week 4 (July 17-21)Week 5 (July 24-28)

Older Division: (Girls entering 1st - 5th grade & Boys entering 1st - 3rd grade)
Week 1 (June 26-30)Week 2 (July 3 -7)Week 3 (July 10-14)
Week 4 (July 17-21)Week 5 (July 24-28)Trip Camp (July 31 - August 4)


Pioneer Program: (Girls entering 6th - 8th grade)
Week 1 (June 26-30)Week 2 (July 3 -7)Week 3 (July 10-14)
Week 4 (July 17-21)Week 5 (July 24-28)Trip Camp (July 31 - August 4)


Extended hours: ($5 per hour)
8:00AM - 10:00AM Mon Tues Wed Thurs Fri
4:00PM - 6:00 PM Mon Tues Wed Thurs Fri
 

     
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.)

     
Tuition
 
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 $200 for the week or $50 a day. $8 extra charge for Thursday.
$50 Additional fee for Pioneer Program 

   

Billing Information

Total Amount
Coupon Code
Card Number
Name on Card
CVV
Billing Address Address:  City: 
State:  Zip: 
Expiration Date
   
Policies and Parental Consent

   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:
Comments
   
Date of Application

 

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Summer: 4230 Middlebelt Road • West Bloomfield, MI 48323 • 248-932-8584 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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