Camp Chibikko Registration Form

I am signing up Camp Chibikko for the week(s) of:

Camp Dates
  • WEEK 1: 7/10/2017 - 7/14/2017
  • WEEK 2: 7/17/2017 - 7/21/2017

Please enter the quantity for all those that apply to your application.

Quantity
Price
Total
Extra T-Shirt
X
$
10.00=
$
0

ONE WEEK ONLY (K-5)

REGISTRATION for one camper for one week only.

X
$
275.00=
$
0

BOTH WEEKS (K-5)

Two weeks of Camp Chibikko

X
$
500.00=
$
0

SIBLING - ONE WEEK ONLY (K-5)

ONE WEEK - SIBLING DISCOUNT

X
$
250.00=
$
0

BOTH WEEKS - SIBLING DISCOUNT (K-5)

Sibling Discount for Both Weeks

X
$
475.00=
$
0

ONE WEEK (JR. HIGH)

One week of Camp Chibikko for Jr. High camper

X
$
250.00=
$
0

BOTH WEEKS (Jr. High)

Both weeks for Jr. High camper

X
$
475.00=
$
0

Jr. High Sibling - DISCOUNT (ONE WEEK ONLY)

Discount for Jr. High sibling - for one week only

X
$
200.00=
$
0

Final Total:
$
0

Parent/Guardian Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

Camper Information

Child Name
Child Date of Birth
Grade
T-Shirt Size
  • Youth Small
  • Youth Medium
  • Youth Large
  • Adult Small
  • Adult Medium
Food Allergies

Sibling Information

Please only fill this section out if you are also enrolling siblings into Camp Chibikko.

First Sibling Name
First Sibling Date of Birth
First Sibling Grade as of 9/2017
First Sibling T-Shirt Size
  • Youth Small
  • Youth Medium
  • Youth Large
  • Adult Small
  • Adult Medium
First Sibling Food Allergies
Second Sibling Name
Second Sibling Date of Birth
Second Sibling Grade as of 9/2017
Second Sibling T-shirt Size
  • Youth Small
  • Youth Medium
  • Youth Large
  • Adult Small
  • Adult Medium
Second Sibling Food Allergies

Emergency Contact Information

Emergency Contact
Relationship
Phone

Acknowledgment and Waivers

I acknowledge that space is limited and that all fees are non-refundable after June 9, 2017.

 

Typing your name in the space below confirms your acknowledgement and serves as your electronic signature.

AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR

 

I authorize the ESGVJCC - Camp Chibikko, as agents to consent to any x-ray, anesthetic, medical or surgical diagnosis for treatment and hospital care deemed advisable and rendered by any licensed physician or surgeon, whether in his office or in a licensed hospital. This authorization is given in advance of any required care to empower the agents to give consent for such treatment, as the physiian may deem advisable. (Section 25.8 of the Civil Code of California)

 

This authorization shall remain effective during the participation of my child(ren).

 

Typing your name in the space below confirms your acknowledgement and serves as your electronic signature.

MINOR PHOTO RELEASE

 

I give the ESGVJCC Camp Chibikko permission to publish in print, electronic, or video format the likeness of image(s) of my child. I release all claims against ESGVJCC Camp Chibikko with respect to copyright ownership and publication including any claim related to use of the materials.

 

Typing your name in the space below confirms your acknowledgement and serves as your electronic signature.

WAIVER & RELEASE

 

In consideration of my child(ren) being permitted to take part in all the ESGVJCC Camp Chibikko's activities, whether public or private, of the East San Gabriel Valley Japanese Community Center (ESGVJCC) - Camp Chibikko and or on said ESGVJCC premises or any other place in the course of said Camp's activities, I do hereby expressly waive and release any and all rights which I or my child(ren) may have to maintain my claim or demand whatsoever against the said Camp and ESGVJCC, its' officers, member teachers, employees or against any other person other than the undersigned or which might ensure as a result of my or my child(ren) being on said Camp Premises or otherwise my or my child(ren)'s participation in any of said Camp activities. This waiver and release shall remain effective during the enrollment of my child(ren) at ESGVJCC Camp Chibikko.

 

Typing your name in the space below confirms your acknowledgement and serves as your electronic signature.

Acknowledgement

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code