Test Page Camp B'nai Ruach Registration 2023 "*" indicates required fields Number of children you are registering:* One Two Three Four Camper 1 - Name* 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 Camper 1 Quantity Price: $15.00 Quantity Camper 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 Camper 2 Quantity Price: $15.00 Quantity Camper 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 Camper 3 Quantity Price: $15.00 Quantity Camper 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 Camper 4 Quantity Price: $15.00 Quantity Is there anything you would like to mention about your children to ensure your camper 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 Are you a member of Congregation B'nai Israel?*YesNoDo you want to add Extended Care to your child(ren)'s camp day?*YesNoCAMP HOURS & EXTENDED CARE Camp hours are 9:00 am - 4:00 pm daily. Extended care is offered from 8:00 am - 9:00 am and 4:00 pm - 6:00 pm. EC weekly rates include morning and afternoon care and can be added to camp tuition discounted at $130 a week. Daily rate is $20 per hour/per child. If your child arrives prior to 9 am or is picked up after 4 pm, you will be billed for extended hours. Camp Pricing Summer 2023 Camp Weeks 1,3,4,5 - CBI Member $350/Non-member $375 Camp Week 2 - CBI Member $300/Non-member $320 Super Early Bird Special - register by April 15 and receive $50 off registration fee - Enter Coupon code SUPER2023 Early Bird Special - register by May 1 and receive $30 off registration fee - Enter Coupon code EARLYBIRDRegistration Fee* Price: $0.00 Weeks your campers 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) Week 1 - Member - No EC (Add # of campers attending this week) Quantity Price: $350.00 Quantity Week 1 - Member - EC (Add # of campers attending this week) Quantity Price: $480.00 Quantity Week 1 - Non Member - No EC (Add # of campers attending this week) Quantity Price: $375.00 Quantity Week 1 - Non Member - EC (Add # of campers attending this week) Quantity Price: $505.00 Quantity Name of Campers Attending Week 1 Week 2 - Member - No EC (Add # of campers attending this week) Quantity Price: $300.00 Quantity Week 2 - Member - EC (Add # of campers attending this week) Quantity Price: $430.00 Quantity Week 2 - Non Member - No EC (Add # of campers attending this week) Quantity Price: $320.00 Quantity Week 2 - Non Member - EC (Add # of campers attending this week) Quantity Price: $450.00 Quantity Name of Campers Attending Week 2 Week 3 - Member - No EC (Add # of campers attending this week) Quantity Price: $350.00 Quantity Week 3 - Member - EC (Add # of campers attending this week) Quantity Price: $480.00 Quantity Week 3 - Non Member - No EC (Add # of campers attending this week) Quantity Price: $375.00 Quantity Week 3 - Non Member - EC (Add # of campers attending this week) Quantity Price: $505.00 Quantity Name of Campers Attending Week 3 Week 4 - Member - No EC (Add # of campers attending this week) Quantity Price: $350.00 Quantity Week 4 - Member - EC (Add # of campers attending this week) Quantity Price: $480.00 Quantity Week 4 - Non Member - No EC (Add # of campers attending this week) Quantity Price: $375.00 Quantity Week 4 - Non Member - EC (Add # of campers attending this week) Quantity Price: $505.00 Quantity Name of Campers Attending Week 4 Week 5 - Member - No EC (Add # of campers attending this week) Quantity Price: $350.00 Quantity Week 5 - Member - EC (Add # of campers attending this week) Quantity Price: $480.00 Quantity Week 5 - Non Member - No EC (Add # of campers attending this week) Quantity Price: $375.00 Quantity Week 5 - Non Member - EC (Add # of campers attending this week) Quantity Price: $505.00 Quantity Name of Campers Attending Week 5 Medical Release/Permission SlipCamper's Pediatrician Name* Camper's Pediatrician Phone* Medical Insurance Carrier* Policy #* Emergency Contact Name* Emergency Contact Phone* Camper 1 Name* Camper 1 Health/Dietary/Restrictions* Camper 1 Allergies* Camper 1 Medications* Camper 2 Name* Camper 2 Health/Dietary/Restrictions* Camper 2 Allergies* Camper 2 Medications* Camper 3 Name* Camper 3 Health/Dietary/Restrictions* Camper 3 Allergies* Camper 3 Medications* Camper 4 Name* Camper 4 Health/Dietary/Restrictions* Camper 4 Allergies* Camper 4 Medications* Agreement* The undersigned parent(s) of campers, 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* I will send a check to the CBI office Credit Card (Visa or MasterCard) Payment Plan - 4 Equal Payments (Available until March 16 for weeks 1&2 and April 1 for weeks 3-5). No exceptions will be made. No refunds after June 22, 2023. Add-ons Always welcome!Questions? Please contact Camp Director - Sheri Galante (310)918-3702 camp@cbi18.org CHECK PAYMENT Please make checks payable to: CBI Camp B’nai Ruach Mail payments to: 2111 Bryan Avenue, Tustin, CA 92782Coupon codes (Apply one at a time)By April 15 - Super Early Bird Special $50 off - Coupon code SUPER2023By May 1 - Early Bird Special $30 off - Coupon code EARLYBIRDTo confirm 4 monthly Payments - Coupon code PAYMONTHLY (expired April 1)Coupon code Total Credit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name