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Activities and Events Gan Israel Summer Camp 2023

Camp Registration Form

1. Child/ren’s Information
Child 1*

First Name Middle Name Last Name
Date of Birth*

Month Day Year
Age as of 10.07.23*
Gender*

MaleFemale
Is the child's mother Jewish?*

Yes
Does he/she suffer from any allergies or take any medication? Please specify if yes.*
Child 2

First Name Middle Name Last Name
Birth Date*

Month Day Year
Age as of 10.07.23*
Gender*

MaleFemale
Is the child's mother Jewish?*

Yes
Does he/she suffer from any allergies or take any medication? Please specify if yes.*
Child 3

First Name Middle Name Last Name
Birth Date*

Month Day Year
Age as of 10.07.23*
Gender*

MaleFemale
Is the child's mother Jewish?*

Yes
Does he/she suffer from any allergies or take any medication? Please specify if yes.*
2. Parent information

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail* Primary email
Mother's Cell Phone*

Area Code Phone Number
Father's Cell Phone

Area Code Phone Number
How did you hear of us?
3. Emergency Information
Emergency Contact*

First Name Last Name
Relationship to child*
Phone Number*

Area Code Phone Number
4. Payment Information

CHF 200.- per child *early bird discount CHF 170.- until the 15th of May
Preferred Payment Method*

Bank TransferCash
PLEASE NOTE:
Registration is complete upon receipt of payment.
Bank Transfer Details

Basler Kantonalbank, CH-Basel
SWIFT-BIC: BKBBCHBB
IBAN: CH25 0077 0254 2231 5200 2

In favor of:
Mordechai Gruzman
Herrengrabenweg 20, 4054 Basel
Photos Agreement*
General comments

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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