Camp B’nai Ruach Junior Counselor Registration "*" indicates required fields Number of Junior Counselors you are registering:* One Two Three Four Child Name - 1* First Last Child 1 - Date of Birth* Month Day Year Child 1 - Grade in September 2023* Child 1 - Gender* Child 1 - T-shirt Size (Included in camp fees)*Youth X-SmallYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeExtra T-shirt Junior Counselor 1 Quantity Price: $15.00 Quantity Junior Counselor 2 - Name* First Last Child 2 - Date of Birth* Month Day Year Child 2 - Grade in September 2023* Child 2 - Gender* Child 2 - T-shirt Size (Included in camp fees)*Youth X-SmallYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeExtra T-shirt Junior Counselor 2 Quantity Price: $15.00 Quantity Junior counselor 3 - Name* First Last Child 3 - Date of Birth* Month Day Year Child 3 - Grade in September 2023* Child 3 - Gender* Child 3 - T-shirt Size (Included in camp fees)*Youth X-SmallYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeExtra T-shirt Junior Counselor 3 Quantity Price: $15.00 Quantity Junior Counselor 4 - Name* First Last Child 4 - Date of Birth* Month Day Year Child 4 - Grade in September 2023* Child 4 - Gender* Child 4 - T-shirt Size (Included in camp fees)*Youth X-SmallYouth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeExtra T-shirt Junior Counselor 4 Quantity Price: $15.00 Quantity Is there anything you would like to mention about your child(ren) to ensure your Junior Counselor has a wonderful time at camp?Parent/Guardian 1 - Name* First Last Parent/Guardian 1 - Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian 1 - Cell Phone*Parent/Guardian 1 - Email* Parent/Guardian 2 - Name First Last Parent/Guardian 2 - Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian 2 - Cell PhoneParent/Guardian 2 - Email Have you registered other children for Camp B'nai Ruach for summer 2023?*YesNoRegistration Fee (Add "1" to quantity to pay 1 registration fee per family) Quantity* Price: $60.00 Quantity Weeks your Junior Counselor are attending camp:* Camp Week 1 (6/26-6/30) Camp Week 2 (7/3-7/7) Camp Week 3 (7/10-7/14) Camp Week 4 (7/17-7/21) Camp Week 5(7/24-7/28) Name of Junior Counselor Attending Week 1 Name of Junior Counselor Attending Week 2 Name of Junior Counselor Attending Week 3 Name of Junior Counselor Attending Week 4 Name of Junior Counselor Attending Week 5 Medical Release/Permission SlipCamper's Pediatrician Name* Camper's Pediatrician Phone* Medical Insurance Carrier* Policy #* Emergency Contact Name* Emergency Contact Phone* Junior Counselor 1 Name* Junior Counselor 1 Health/Dietary/Restrictions* Junior Counselor 1 Allergies* Junior Counselor 1 Medications* Junior Counselor 2 Name* Junior Counselor 2 Health/Dietary/Restrictions* Junior Counselor 2 Allergies* Junior Counselor 2 Medications* Junior Counselor 3 Name* Junior Counselor 3 Health/Dietary/Restrictions* Junior Counselor 3 Allergies* Junior Counselor 3 Medications* Junior Counselor 4 Name* Junior Counselor 4 Health/Dietary/Restrictions* Junior Counselor 4 Allergies* Junior Counselor 4 Medications* Agreement* The undersigned parent(s) of Junior Counselor, registered here, hereby consent to his/her participation in the Camp B’nai Ruach camp program.Waive Claims* In consideration of Camp B’nai Ruach acceptance of my/our child as a participant in this youth activity, I/we both as legal guardians of my/our child hereby waive any and all claims against Camp B’nai Ruach its agents and its employees, that may arise out of any injury, loss or damage suffered by my/our child during the activity as a result of his/her leaving the group without authorization or failing to follow any of the camp rules.*Waive Claims* I/We hereby authorize Camp B’nai Ruach and its employees and agents to act as my/our agent to consent to or arrange any emergency medical treatment that may be deemed necessary by an attending physician with respect to any illness or injury suffered by my/our child on said activity.*Waive Claims* I/We understand and consent to photographing, reproduction, use and retention of photographs, film, and/or video of my/our child(ren) taken by and/or Camp B’nai Ruach for use in education, publicity, and promotional activities in any and all publication and other media without limitation or reservation.*Parent Signature* Date* MM slash DD slash YYYY Payment InformationPayment Method - if selecting monthly payments please ensure that you apply coupon code "PAYMONTHLY below* I will send a check to the CBI office Credit Card (Visa or MasterCard) CHECK PAYMENT Please make checks payable to: CBI Camp B’nai Ruach Mail payments to: 2111 Bryan Avenue, Tustin, CA 92782Total Credit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name
