Non CC Camp Registration Form - ChabadPalisades.com

Child's Information

Name*

First Name Last Name

Date Of Birth*

Month Day Year

Gender*

MaleFemale

T-Shirt*

Weeks Attending*

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?*

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*

School Information

Name of School*

Grade entering in September 2023*

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 tshirt)

Early Bird Rate: (Valid Through March 26th)
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 RateTwo Campers rate

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

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

Extras

Lunch ($45 Per Week)Extra 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

Lunch Two Camper

Total

$0.00

Which method of payment?*

CashCheck - Please make check payable to Chabad Palisades 17315 Sunset Blvd. Pacific Palisades, CA 90272Venmo/Zelle - 310-628-4444

If you are paying by Venmo or Zelle please write how your name will show up.

Notes:

CGI Palisades Registration Form - Non-Credit Card