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Riverside

Camp Gan Israel

fun forever!

ב"ה

Registration

Campers Information
Camper 1
Full Name*
First NameLast Name
Age*
Grade*
Attending:*
Week 1Week 2Both weeks
Camper 2
Full Name
First NameLast Name
Age
Grade
Attending:
Week 1Week 2Both weeks
Camper 3
Full Name
First NameLast Name
Age
Grade
Attending:
Week 1Week 2Both weeks
Parents Information
Legal Guardian*
First NameLast Name
E-mail*

Mailing Address*

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

Emergency Contact #1*
First NameLast Name
Phone Number*
Area CodePhone Number
Emergency Contact #2
First NameLast Name
Phone Number
Area CodePhone Number
Allergy Info:Please provide any allergy or other medical information we should be know about:
Payment Information
Camp Fees:
One Week: $219 - Register By June 15 $199
Both Weeks: $419 - Register by June 15 $379
Discounts: Sibling Children additional 5% discount
Amount to charge today:*
$
If applicable: Please charge the balance on:
Total
$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Releases: As the parent(s) or legal guardian of the above child/ren, I authorize any adult acting on behalf of Camp Gan Israel/Chabad of Riverside to transport my child/ren by means of transportation provided. My child/ren is allowed to participate in all off campus activities and trips. In the event of an emergency, when I am not available, I authorize a representative of Cam Gan Israel/ Chabad of Riverside to make such arrangements as considered necessary, to receive medical or hospital care. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit Camp Gan Israel/Chabad of Riverside personnel will try, but are not required, to communicate with me/us prior to such treatment.
*
I agree to the terms and conditions above.
Type Initials:*
Comments:
Should be Empty:

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