JC Camp Registration Form - Chabad Jewish Community Center of Pacific Palisades

CGI Palisades Junior Counselor Registration Form
Child's Information
Name*
First Name Last Name
Date Of Birth*

Month Day Year
Gender*

MaleFemale
T-Shirt*
Weeks Attending*

Full Summer: June 29 - July 31Week 1: June 29 - July 2Week 2: July 6 - 10Week 3: July 13 - 17Week 4: July 20 - 24Week 5: July 27 - 31
School Information
Name of School*
Grade entering in September 2026*
Parent Information
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
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 pool. 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
Notes:
Please read through the Junior Counselor Agreement with your child and bring it to camp signed before the first day of camp.
Should be Empty:

CGI Palisades Junior Counselor Registration Form