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Activities and Events Gan Israel Camp Registration Form

Camp Registration Form

1. Child/ren’s Information
Child 1*
First NameMiddle NameLast Name
Birth Date*
MonthDayYear
Gender*
MaleFemale
Does he/she suffer from any allergies or take any medication? Please specify if yes.*
Child 2
First NameMiddle NameLast Name
Birth Date
MonthDayYear
Gender
MaleFemale
Does he/she suffer from any allergies or take any medication? Please specify if yes.
Child 3
First NameMiddle NameLast Name
Birth Date
MonthDayYear
Gender
MaleFemale
Does your child 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

Mother's info*
First NameLast Name
Work Phone
Area CodePhone Number
E-mail*Primary email
Cell Phone*
Area CodePhone Number
Father's info
First NameLast Name
Work Phone
Area CodePhone Number
E-mail
Cell Phone
Area CodePhone Number
How did you hear of us?
3. Emergency Information
Emergency Contact*
First NameLast Name
Relationship to child*
Phone Number*
Area CodePhone Number
4. Payment Information
Main Camp: CHF 150.- Kiddie Camp: CHF 100.-
Preferred Payment Method*
Bank TransferCash
Bank Transfer Details
Basler Kantonalbank, CH-Basel
SWIFT-BIC: BKBBCHBB
IBAN: CH52 0077 0254 2231 5200 1
In favor of:
Mordechai Gruzman
Colmarerstrasse 71, 4055 Basel
Account No 254223152001
Photos Agreement*
General comments
Should be Empty: