My Little Kaytana Summer Camp Application Form - Summer 2022Child's Name*First NameLast NameGender*MaleFemaleBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearHebrew NameAddress*Street AddressStreet Address Line 2CityState / ProvincePostal / 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 SaharaYemenZambiaZimbabweOtherCountryMother's name*Work Phone*Area CodePhone NumberCell Phone*Area CodePhone NumberE-mail*Father's Name*First NameLast NameWork Phone*Area CodePhone NumberCell Phone*Area CodePhone NumberE-mail*Parent's Marital StatusMarriedDivorcedSeparatedOtherIs your child currently attending school?*YesNoName of SchoolAre 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 NameLast NamePhone Number*Area CodePhone NumberRelationshipEmergency Contact 2*First NameLast NamePhone Number*Area CodePhone NumberRelationshipThe following people are authorized to pick up my child from My Little Gan during Summer Camp 2021.Full Name*First NameLast NamePhone Number*Area CodePhone NumberRelationship*Full NameFirst NameLast NamePhone NumberArea CodePhone NumberRelationshipFull NameFirst NameLast NamePhone NumberArea CodePhone NumberRelationshipIs child receiving any services?*Child's t-shirt size2T3T4T5T6T7T2 week optionJuly 5 - July 15 (deduct $50)July 11 - July 22July 18 - July 29July 25 - August 5August 1-August 12August 8-August 19August 15-August 263 week optionJuly 5-July 22 (deduct $50)July 11-July 29July 18-August 5July 25-August 12August 1- August 19August 8-August 264 week optionJuly 5 28-July 29 (deduct $50)July 11-August 5July 18-August 12July 25-August 19August 1-August 265 week optionJuly 5-August 5 (deduct $50)July 11-August 12July 18-August 19July 25-August 266 week optionJuly 5-August 12 (Deduct $50)July 11-August 19July 18-August 267 week optionJuly 5-August 19 (Deduct $50)July 11-August 268 week optionJuly 5-August 26Extended Care3:00-5:00 pmSchedule Times*9:00 am-12:15 pm9:00 am-3:00 pmI would like to receive news and updates by emailDuring 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 NameLast NameChild's Name*First NameLast NameSignature - please enter initials*Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year 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 1Parent 2Once registration is complete, you will receive email confirmation followed by a contract.SubmitOption 1Option 2Option 3Should be Empty: This page uses TLS encryption to keep your data secure.