Camp Registration Form

Child's Information
Name*

First Name Last Name
Date Of Birth*

Month Day Year
Gender*

MaleFemale
T-Shirt*
Weeks Attending*

Full Summer: July 1 - August 2Week 1: July 1 - 5Week 2: July 8 - 12Week 3: July 15 - 19Week 4: July 22 - 26Week 5: July 29 - August 2
School Information
Name of School*
Grade entering in September 2024*
Please select all that are appropriate*

Child was born to a Jewish motherThere are conversions to Judaism in the child's maternal familyChild is not Jewish but interested in attending Gan IzzyChild is adopted in to a Jewish family
Is your child enrolled in a Hebrew School?*

YesNoNo, but I am interested in finding out more information about the Palisades Jewish Enrichment Club.
Parent/Guardian 1*

First Name Last Name
Cell Phone*
E-mail*

Address*

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

Maritial Status

MarriedSingleDivorced/Separated
Parent/Guardian 2

First Name Last Name
Cell Phone

Address (If different then above)

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

Additional Contact (In Case of Emergency)
Emergency Contact Name*

First Name Last Name
Phone Number*
Relationship*
How did you hear about us?*

MailerEmailFacebookInternet SearchAttended PreviouslyFriendOther
Medical Information
Insurance Provider*
Policy #*
Name of Doctor*

First Name Last Name
Doctor's Phone*
Allergies (If yes, please explain.)*
Does your child take medication regularly? (If yes, please specify.)*
Does your child have any medical (physical, emotional or mental) conditions we should be aware of?**
Additional medical information
Do you want to register another child?*

YesNo
Name*

First Name Last Name
Date Of Birth*

Month Day Year
Gender*

MaleFemale
T-Shirt*
Weeks Attending*

Full Summer July 1 - August 2Week 1: July 1 - 5Week 2: July 8 - 12Week 3: July 15 - 19Week 4: July 22 - 26Week 5: July 29 - August 2
School Information
Name of School*
Grade entering in September 2024*
Is your child enrolled in a Hebrew School?*

YesNoNo, but I am interested in finding out more information about the Palisades Jewish Enrichment Club.
Medical Information
Insurance Provider*
Policy #*
Name of Doctor*

First Name Last Name
Doctor's Phone
Allergies (If yes, please explain.)*
Does your child take medication regularly? (If yes, please specify.)*
Does your child have any medical (physical, emotional or mental) conditions we should be aware of?**
Additional medical information
Permissions And Waiver

Check each box after reading the waiver.
In the event that neither parent nor the emergency person can be contacted, Camp Gan Israel has my permission to render any necessary first aid or to secure care by a physician to my child while attending camp.*

I Agree
I hereby give permission for my child to be taken off-campus on all outings by Camp Gan Israel for Field trips, hiking or the beach. This completed form may be photocopied for outings. I give permission to Camp Gan Israel to use camp photos of my children in any camp publicity.*

I Agree
I understand that Gan Israel Day Camp is carrying limited liability insurance protecting the camp premises against physical damage and covering the camp staff against negligence. Nevertheless, I agree to accept complete responsibility for damages caused by my child and for injuries incurred and agree to hold Chabad of Pacific Palisades and Camp Gan Israel and its staff harmless and I hereby release said parties from all liability except in cases of gross negligence.*

I Agree
CAMP RATES:

Registration Fee Per Camper: $50
(Includes the camp t-shirt)

Early Bird: (Valid Through March 1st)
Full Summer: $2,250 ($450/Week), 1 Week: $475, 2 - 4 Weeks: $460/Week

Standard Rate:
Full Summer: $2,375 ($475/Week), 1 Week: $500, 2 - 4 Weeks: $485/Week
Optional:

Additional T-Shirts: $15 Per T-Shirt, Lunch: $45/week
Payment & submission
A one time $50 registration fee per camper is automatically added at check-out (includes a Gan Izzy tshirt).
Please select which rate option you will be going with:*

One Camper Rate:Two Campers Rate:
One Camper Rate : Please select how many weeks you will be signing up for:

Full Summer: $2,375One Week $500Two Weeks $970Three Weeks $1,455Four Weeks $1,940
Two Campers Rate: Please select how many weeks you will be signing up for:

Full Summer: $4,750 (Don't select the other weeks if you will be coming for the full summer)One Week $1000Two Weeks $1940Three Weeks $2,910Four Weeks $3,880
Extras

Lunch ($45 Per Week)Additional T- Shirt $15
Additional T-Shirt

One T-Shirt $15Two T-Shirts $30Three T-Shirts $45
Lunch

One Camper ($45 per week)Two Campers ($90 per week)
Lunch One Camper

Full Summer: $225One Week $45Two Weeks $90Three Weeks $135Four Weeks $180
Lunch Two Camper

Full Summer: $450One Week $90Two Weeks $180Three Weeks $270Four Weeks $360
Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

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

City

State / Province

Postal / Zip Code

Country

Notes:
Should be Empty:

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