Camp Registration form Camper InformationName* First Last Jewish Name*Date of birth* Date Format: MM slash DD slash YYYY Age*Gender* Boy Girl School Attending*Siblings Sibling 1 Sibling 2 Sibling 3 Sibling 1 First Last Jewish NameDate of birth Date Format: MM slash DD slash YYYY AgeGender Boy Girl School AttendingSibling 2 First Last Jewish NameDate of birth Date Format: MM slash DD slash YYYY AgeGender Boy Girl School AttendingSibling 3 First Last Jewish NameDate of birth Date Format: MM slash DD slash YYYY AgeGender Boy Girl School AttendingAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent InformationMother Name* First Last Mother Cell*Mother Email* Mother Occupation*Father Name* First Last Father Cell*Father Email* Father Occupation*All camp correspondence and updates will be sent via email. Please indicate your email of preference* Medical InformationEmergency Contact 1*Contact 1PhoneRelationship to child Emergency Contact 2*Contact 2PhoneRelationship to child Family Physician*NamePhoneAddress Does your child/ren have any Allergies, medications or medical concerns Camp Gan Israel needs to be aware of?*Camp ShirtsCamp Shirt Size*Campers will receive 1 complimentary camp shirt to be worn on ALL trip days.Youth XSYouth SYouth MYouth LYouth XLAdult SAdult MI would like to purchase additional shirts for $10/shirt 1 shirt 2 shirts Sibling 1 Camp Shirt Size*Campers will receive 1 complimentary camp shirt to be worn on ALL trip days.Youth XSYouth SYouth MYouth LYouth XLAdult SAdult MI would like to purchase additional shirts for $10/shirt 1 shirt 2 shirts Sibling 2 Camp Shirt Size*Campers will receive 1 complimentary camp shirt to be worn on ALL trip days.Youth XSYouth SYouth MYouth LYouth XLAdult SAdult MI would like to purchase additional shirts for $10/shirt 1 shirt 2 shirts Sibling 3 Camp Shirt Size*Campers will receive 1 complimentary camp shirt to be worn on ALL trip days.Youth XSYouth SYouth MYouth LYouth XLAdult SAdult MI would like to purchase additional shirts for $10/shirt 1 shirt 2 shirts Payment InformationPayment Details*1 Week2 Weeks3 WeeksTotal Campers*Please enter a number from 1 to 4.Total $0.00 Payment Method*Credit CardWill Send CheckCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Parental ConsentConsent*Parental Consent Images - Camp Gan Israel is hereby granted permission to use any individual or group photo or video showing our child(ren) involved in camp activities. Damage - I will be responsible for any loss, damage or destruction by camper to any property of Camp Gan Israel or to any property for which the Camp is liable or chargeable. Permission to participate – I give permission for my child to participate in all camp activities and trips on site and off site. Medical Care – I have filled out the Medical Information section above. I understand that my child may be dismissed during a camp day, due to illness, at the discretion of the camp, and I agree to abide by the director’s decision. The parent who signs this registration form represents that s/he has full authority to do so and will be responsible for payment of the camp fees. I agreeCovid-19 - Waiver of Liability*The novel coronavirus, COVID 19, has been declared a worldwide pandemic by the World Health Organization. COVID 19 is reported to be extremely contagious. The virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. COVID 19 can cause serious and potentially life-threatening illness and even death. As a result, federal, state, and local governments and health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. The Camp Gan Israel at the Jewish Center of Cape Coral, Inc. and Chabad of Cape Coral, Inc. (the “CAMP”) has put in place preventative measures that may reduce the spread of COVID 19; however, the CAMP cannot guarantee that you or your child(ren) will not become exposed to, or infected with, COVID 19. Further, attending the CAMP and/or participating in its programs could increase your risk and your child(ren)’s risk of contracting COVID 19. By signing this Assumption of Risk, Release and Waiver of Liability Agreement, I acknowledge the contagious nature of COVID 19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID 19 by attending and/or participating in the CAMP’s programs, and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID 19 at the CAMP may result from the actions, omissions, or negligence of myself and others, including, but not limited to, CAMP employees, volunteers, vendors, classmates, other children/program participants and/or their families. In consideration of my child(ren)’s attending the CAMP, I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the CAMP or participation in CAMP programming (“Claims”). On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless the CAMP, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto, including any Claims based on the actions, omissions, or negligence of the CAMP, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in, or attendance at, any CAMP program. I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY AGREEMENT, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY AND MY CHILD(REN)’S RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE. I have read the Covid-19 Waiver of Liability and understand the risks involved. I will submit a signed waiver on the first day of camp. כ״ה בניסן ה׳תשע״ט (2019-04-30)
