Winter Camp Registration - Chabad House of Greater Hartford

Winter Camp Registration form

Register Online

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us.

Please note that one registration form per child is needed.

Child Profile

Childs's First Name
Last
Hebrew Name
DOB
School
Grade
Dates Attending	Dec. 28 Dec. 29 Dec. 30 Dec. 31 Jan 1

Additional Child Profile

Childs's First Name
Last
Hebrew Name
DOB
School
Grade

Parent Information

Father's Name
Phone
Mother's Name
Phone
Is maternal mother Jewish
Address
City
State
Zip
Email Address

Emergency Information

Emergency Contact 1
Phone
Emergency Contact 2
Phone

CONFIDENTIAL: Does your child have any allergies, medical condition or other challenges we should be aware of?
If yes, please describe them and indicate special precautions or care needed.

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Camp Gan Israel to hospitalize or secure treatment for my/our child, I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Camp Gan Israel personnel will try, but are not required, to communicate with me/us prior to such treatment. I also give permission for my/our child to be in photos taken during camp activities and may be used in camp marketing and publicity.

Method of Payment:
Please make checks payable to: Chabad House 2352 Albany Avenue West Hartford CT 06117	Will send Check or Cash Credit

Credit Card Info:
First Name:
Last Name:
Address:
City, State and Zip:
Card Type
Credit Card Number:
Exp. Date:	(mm/yyyy)

Security Code:

(Last 3 digits on back of card)