Please complete all sections of this form to register your son. Child Information Full Name* First Name Last Name Jewish Name* Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year School* Current Grade* 4th Grade5th Grade6th Grade7th Grade8th Grade Parent's Information Add Parents info* Add Father's infoAdd Mother's info Father Name* First Name Last Name Fathers Jewish Name* Copy first name if no Jewish name Father Cell Phone* Father E-mail* Mother Name* First Name Last Name Mother's Jewish Name* Copy first name if no Jewish name Mother Cell Phone* Mother E-mail* Is the child's biological mother Jewish?* Yes. Jewish from birthYes. Converted to JudaismNot JewishMother is adopted Which Rabbi oversaw the conversion* Please note that our policy is that conversions must have been performed by a Rabbi approved by the Chief Rabbinate of the State of Israel Information pertinent to the Ski trip Please keep in mind that for your child's safety and enjoyment, we need this information to be completely accurate Height* 3.1 - 3.6 FT3.7 - 3.11 FT4.0 - 4.5 FT4.6 - 4.10 FT4.11 - 5.1 FT5.2 - 5.5 FT5.6 - 5.10 FT5.11 - 6.4 FT Weight* 22 - 29 LBS30 -38 LBS39 - 47 LBS48 - 56 LBS57 - 66 LBS67 - 78 LBS79 - 91 LBS92 - 107 LBS108 - 125 LBS126 - 147 LBS148 - 174 LBS175 - 209 LBS210+ LBS Shoe Size Type* US YouthUS Men Shoe Size* Ski Level* BeginnerModerateAdvanced Medical and Emergency information Emergency Contact Name* First Name Last Name Emergency Contact Phone Number* Relationship to child* Does your child take any medication?* YesNo Please list all medications your child takes and when they need to be taken.* Does your child have any food or drug allergies?* YesNo Please list all food or drug allergies your child has* Does your child have any special conditions we need to be aware about* YesNo Please explain any special conditions your child may have* Name of Physician* First Name Last Name Physician Phone Number* References Please list 2 references and their contact info. Examples: Current or recent teacher, principal, camp director Reference 1 Full Name* First Name Last Name Reference 1 relationship* Reference 1 Phone Number* Reference 2 Full Name* First Name Last Name Reference 2 relationship* Reference 2 Phone Number* Who referred you to our program? Payment Info Winter Camp Tuition for the one week residential program is $1,000. This helps cover the cost of lodging, 3 hot meals a day, all activities and trips and transportation. For those in need we have an option to choose the subsidized price of $770 If you are in need of further scholarship, please complete a scholarship application in the forms tab. Scholarships are limited and are on a first come first served basis. Tuition cost* $1000$770 Total $0.00 Yes, I'd like to donate the cost of processing this transaction by adding 3% Payment Credit Card Other: Zelle, Check/Cash Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearTo save us the CC processing fees, please consider sending your payments via Zelle to: [email protected]To pay by Check, please mail to:Camp F.R.E.E. - Gan Israel380 East 45th Street, FL1Brooklyn, NY 11203Feel free to contact us to arrange a Cash payment Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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