If you would like to enroll a child in Kiddy Camp (ages 4 and younger), please contact the office at [email protected] to ensure that there is still availability. If you have any questions or comments, please feel free to reach out to the office at [email protected] Sibling discount applies to additional child/ren registering for the entire summer and cannot be combined with the early bird discount. Kiddy Kamp is for children born 2019-2020. Gan Izzy is for children entering Pre-1A until age 10. Pioneer Program is for girls aged 11-12. 1. Child/ren’s Information Child 1* First Name Middle Name Last Name Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender* MaleFemale Grade entering 9/23* School Attending* Sessions* Entire Summer (July 3-August 17) $1700Session One (July 3-July 28) $1050Session Two (August 1-August 17) $850 Child 2 First Name Middle Name Last Name Birth Date 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender MaleFemale Grade entering 9/23 School Attending Sessions Entire Summer (Sibling Discount) (July 3-August 17) $1550Session One (July 3-July 28) $1050Session Two (July 31-August 17) $850 Child 3 First Name Middle Name Last Name Birth Date 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender MaleFemale Grade entering 9/23 School Attending Sessions Entire Summer (Sibling Discount) (July 3-August 17) $1550Session One (July 3-July 28) $1050Session Two (July 31-August 17) $850 If you have additional children please contact us. Are you interested in Extended Care? Yes No Are you interested in Transportation? Transportation availability is subject to location restrictions Yes No Does your child receive services during the school year? (If yes, please describe)* 2. Parent information Phone Number* Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Mother's info* First Name Last Name Occupation* Work Phone* Area Code Phone Number E-mail* Primary email Cell Phone* Area Code Phone Number Father's info* First Name Last Name Occupation* Work Phone* Area Code Phone Number E-mail* Cell Phone* Area Code Phone Number How did you hear of us? Mailer Email Facebook Newspaper Ad Internet Search Attended Previously Other Marital Status* Married Single Divorced/Separated 3. Emergency Information Emergency Contact (OTHER THAN PARENT)* First Name Last Name Phone Number* Area Code Phone Number Relationship* Pediatrician & Insurance First Name Last Name Phone Number Area Code Phone Number Insurance Policy # Camp's grand trip at the end of the summer is to Six Flags. (Excluding Mini Gan Izzy and Kiddy Camp) Does your child have a season pass or would you like to purchase a ticket with camp?* Season PassPurchase ticket with camp($45 will be added to your invoice)Will not attend 4. Payment Information A $150 registration fee is taken as a nonrefundable deposit Total $0.00 I would like to pay today:Full amount$150.00 minimum$ Payment* Credit Card Paypal Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Expiration Year Paypal has been selected. Payment will take place on the next page. Special Needs or Allergies* Please contact the Camp office for scholarship opportunities or special requests. I UNDERSTAND THAT MY CHILD'S ENROLLMENT IN CAMP IS CONTINGENT ON COVID-19 PROTOCOLS AND PROCEDURES I grant permission for my child to participate in all camp activities, including swimming and trips away from camp grounds (dates and destinations to be provided at a later date). I understand that if my application is not filled out completely or the required payments are not enclosed, my application will not be processed and will be returned. I agree to disclose any behavioral help my child receives during the school year, to ensure that Camp has the ability to accomodate my child's needs. I agree that my child may be photographed, and their pictures may be used in future camp promotional materials, including, but not limited to the brochure and the CGI website. No camper will be permitted into camp without all forms completed (including medical and application) and all financial obligations satisfied. CGI is not responsible for personal property brought to camp. If the Camper’s conduct is harmful to the best interests of CGI Day Camp, the Camper may be dismissed at the sole discretion of the Director with no refund nor reduction of fee. I will pay half of my child’s tuition no later than June 30 and the remainder by July 30. 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