Registration - ChabadRM.com

Please fill out this COMPLETELY and SIGN so that we can register your child(ren).

Discount code

Number of Campers Registering:*

Number of Campers Registering:* Discounted

Number of Campers Registering: Full Scholar

PARENT INFORMATION

Mother's Name:*

First Name Last Name

Address:*

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

Home Number:*

Area Code Phone Number

Cell Number:*

Area Code Phone Number

E-mail:*

Is Mother Jewish:*

By birthConvertNeither

Father's Name:*

First Name Last Name

Address Same as above:

YesNo

Address (If different than above):

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

Cell Number:*

Area Code Phone Number

Home Number:*

Area Code Phone Number

E-mail:*

Is Father Jewish*

By birthConvertNeither

CAMPER INFORMATION

Camper 1: *

First Name Last Name

Camper 1 Hebrew Name*

1) Gender:*

MF

1) Date of Birth:*

Month Day Year

1) Grade (Fall 2024):*

1) Age:*

1) School Attending (Fall 2024):*

1) T-Shirt Size*

1) Does your child have any allergies or dietary restrictions?*

NoYes

If yes, please explain:

1) Does your child have any health issues that we need to know about?*

NoYes

If yes, please explain:

If you are looking to enroll in WEEK 1 ONLY or BOTH WEEKS,
please contact [email protected]

1) Attending:*

Week 2 - $325

1) Attending (Discounted):*

Week 2 - $292.50

1) Attending (Scholar):

Week 2

**If you are only registering one camper, please skip to "Emergency Contact Information"**

Camper 2:

First Name Last Name

Camper 2 Hebrew Name:

2) Gender:

MF

2) Date of Birth:

Month Day Year

2) Grade (Fall 2024):

2) Age:

2) School Attending (Fall 2024):

T-Shirt Size*

2) Does your child have any allergies or dietary restrictions?*

NoYes

If yes, please explain:

2) Does your child have any health issues that we need to know about?*

NoYes

If yes, please explain:

2) Attending:*

Week 2 - $308.75

2) Attending (Discounted):*

Week 2 - $276.25

2) Attending (Scholar):

Week 2

Camper 3:

First Name Last Name

Camper 3 Hebrew Name:

3) Gender:

MF

3) Date of Birth:

Month Day Year

3) Grade (Fall 2024):

3) Age:

3) School Attending (Fall 2024):

3) T-Shirt Size*

3) Does your child have any allergies or dietary restrictions?*

NoYes

If yes, please explain:

3) Does your child have any health issues that we need to know about?*

NoYes

If yes, please explain:

3) Attending:*

Week 2 - $308.75

3) Attending (Discounted):*

Week 2 - $276.25

3) Attending (Scholar):

Week 2

MEDICAL/EMERGENCY INFORMATION
Please list at least one emergency contact other than the child's parents.

1. Emergency Contact Name [other than parents]:*

First Name Last Name

Relationship to Child:*

Home Phone*

Area Code Phone Number

Cell Phone*

Area Code Phone Number

2. Emergency Contact Name [other than parents]:

First Name Last Name

Relationship to Child:

Home Phone:

Area Code Phone Number

Cell Phone:

Area Code Phone Number

PHYSICIAN CONTACT INFORMATION

Name of Child's Physician or Medical Facility:*

Phone Number:*

Area Code Phone Number

PAYMENT INFORMATION

DATES & RATES:

$325
June 10-14
June 17-21

5% Sibling discount

I am registering for:

Total:

$0.00

Payment:

Credit Card Check or Scholarship Fund

Postal / Zip Code

Country

As the parent(s) or legal guardian(s) of child/ren noted above, I/we authorize any adult acting on behalf of Camp Gan Israel of Coachella/Chabad of Rancho Mirage, to hospitalize or secure treatment for my child. I further agree to pay for all charges for that care and/or treatment. It is understood that, if time and circumstances reasonably permit, the camp will try to communicate with me prior to such treatment.

As parents/guardians, we agree that we will be responsible for any loss, damage or destruction by our camper to any property of Camp Gan Israel or to any property for which the camp is liable or chargeable.

I/we hereby give permission for my child to attend all field trips and outings sponsored by the Camp Gan Israel of Coachella/Chabad of Rancho Mirage, and be transported to and from the field trips and outings.

I also allow my child to be photographed/videoed while participating in camp activities. I/we understand that these photographs/videos may be used for publicity purposes.

By typing my name and the date below, I certify that the information on this application is true and correct and that I have read, and approve, the policies listed above.

Please date and sign. *

Full Name:*

First Name Last Name

Date:*

Month Day Year