Register

Submitter's Information
Full Name*
First Name Last Name
E-mail*
I would like to receive news and updates by email
Camper's General Information
Child's First Name*
Child's Last Name*
Child's Hebrew Name (Optional)
Date Of Birth*

Month Day Year
T-Shirt Size*

XS - YouthS - YouthM - YouthL - YouthXL - Youth
Grade Entering in the Fall*
Parents' Information
Parent / Guardian #1*
First Name Last Name
E-mail*
Phone Number*
Is Parent / Guardian #1 Jewish?*

YesNo
Parent / Guardian #2*
First Name Last Name
E-mail*
Phone Number*
Is Parent / Guardian #2 Jewish?*

YesNo
Other Information

Address*

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

Primary Care Provider*
Name of Practice*
Is this Camper covered by health/accident insurance or Public Health Care?*

YesNo
Insurance Provider*
Policy Number*
Does your child have any medical conditions or allergies? (If yes, please describe)
Will your child be needing to take any medications during camp? If yes, please describe.
To better care for your camper: Please provide any additional information about the camper’s behavior or physical, mental, emotional, and social health that you think important or that may affect the camper’s ability to participate in the Camp program (shyness, learning style, etc.) List any strategies used to manage the concern or enhance the camper’s ability.
Emergency Info
Emergency Contact Name (Other than parents)*
First Name Last Name
Emergency Contact Number*
Emergency Contact's Relationship to Child*
Signatures
Medical Waiver and Authorization*

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.
Agreement of Terms*

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.
Audio/Visual Image Release*

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.
Acknowledgement of Risk and Assumption of Personal Responsibility*

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.
Electronic Signature*
Camp Dates Attending / Payment
Please look over our camp schedule and choose the best options for you and your child.

Kosher, balanced lunches and two snacks are provided daily and are included in the prices listed. A camp T-shirt and all trips are also included in the price. For any changes to your form, please call or email us.

Dates:

Week #1: June 15 - 19
Week #2: June 22 - 26

CAMP FEE

Standard Camp Day (9:00 AM - 3:30 PM):
$360 per week

Thanks to the Barbara Rosenthal CGI Scholarship Fund, at Camp Gan Israel, we never turn children away due to a lack of funds. Scholarship assistance is available upon request. Please call our office to discuss (323) 308-5727 or send us an email rabbi@cvchabad.org. Additionally please signal your interest in the camp scholarship by ticking off the option in the sections below.
Camp Dates*

Week #1: June 15 - 19Week #2: June 22 - 26
Total Days of Camp*
Pay now with Credit CardPay with Cash / CheckI'm interested in pursuing a Camp Scholarship with the Barbara Rosenthal CGI Camp Scholarship Fund
Total

$0.00

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

Questions Or Comments
We'd be happy to help!
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Submitter's Information

Camper's General Information

Parents' Information

Other Information

Emergency Info

Signatures

Camp Dates Attending / Payment

Dates:

CAMP FEE

Questions Or Comments