My Little Kaytana Summer Camp Application Form - Summer 2025 Child's Name* First Name Last Name Gender* MaleFemale Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Hebrew Name Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Mother's name* Work Phone* Area Code Phone Number Cell Phone* Area Code Phone Number E-mail* Father's Name* First Name Last Name Work Phone* Area Code Phone Number Cell Phone* Area Code Phone Number E-mail* Parent's Marital Status MarriedDivorcedSeparatedOther Is your child currently attending school?* YesNo Name of School Are you affiliated with a synagogue? Which? Are there any allergies or medical issues we should be aware of?* Is Mother and/or Father Jewish?* Please provide contact information for two people that we can contact in case of emergency (if we cannot reach either parent): Emergency Contact 1* First Name Last Name Phone Number* Area Code Phone Number Relationship Emergency Contact 2* First Name Last Name Phone Number* Area Code Phone Number Relationship The following people are authorized to pick up my child from My Little Gan during Summer Camp 2021. Full Name* First Name Last Name Phone Number* Area Code Phone Number Relationship* Full Name First Name Last Name Phone Number Area Code Phone Number Relationship Full Name First Name Last Name Phone Number Area Code Phone Number Relationship Is child receiving any services?* Child's t-shirt size 2T3T4T5T6T 2 week option June 23 - July 3 (deduct $65/40)June 30 - July 11 (deduct $65/40)July 7 - July 18July 14 - 25July 21 - August 1July 28- August 8August 4 -August 15 3 week option June 23-July 11 (deduct $65/40)June 30-July 18 (deduct $65/40)July 7-July 25 July 14-August 1 July 21- August 8July 28 -August 15 4 week option June 23 - July 18 (deduct $65/40)June 30-July 25 (deduct $65/40)July 7-August 1 July 14-August 8 July 21 -August 15 5 week option June 23-July 25 (deduct $65/40)June 30-August 1 (deduct $65/40)July 7-August 8 July 14-August 15 6 week option June 23-August 1 (Deduct $65/40)June 30-August 8 (deduct $65/40)July 7-August 15 7 week option June 24-August 9 (Deduct $130/80)July 1-August 16 (deduct $190/115) 8 week option June 23- August 15 Extended Care 3:00-5:00 pm8:00-9:00 amuntil 6:00 pm Schedule Times* 9:00 am-12:15 pm9:00 am-3:00 pm I would like to receive news and updates by email During camp, the children will be spending time outside. You may wish to provide us with sunscreen for protection while your child enjoys outdoor play.If you would like for us to apply sunscreen to your child, please provide us with an unexpired bottle of sunscreen, labeled with your child’s first and last name. Please apply sunscreen before camp begins each day and we will reapply before going outside. As with any topical medication or cream, the first application of any brand of sunscreen should be applied at home in order to evaluate your child’s possible allergic reaction to that product. I give My Little Gan staff permission to apply the provided sunscreen. Full Name* First Name Last Name Child's Name* First Name Last Name Signature - please enter initials* Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year PARENTAL CONSENTBy writing my name in the box below I agree to the following terms: I hereby permit my child to participate in all activities at My Little Kaytana Summer camp 2020 at My Little Gan at Chabad of Hoboken, on-site, off-site and on any trips. I release Chabad of Hoboken, My Little Gan and all individuals from any liability arising out of any injury to my child. 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. In the event of a medical or surgical emergency, I grant permission to the physician designated by Chabad of Hoboken and/or My Little Gan to hospitalize, secure proper treatment for and order injections, anesthesia or surgery for my child. Furthermore I understand that payment for medical services is solely the family’s responsibility. Parent 1 Parent 2 Once registration is complete, you will receive email confirmation followed by a contract. Submit Option 1Option 2Option 3 Should be Empty: This page uses TLS encryption to keep your data secure.