Register - My Little Gan

Child's Name*

First NameLast Name

Gender*

MaleFemale

Birth Date*

MonthDayYear

Hebrew Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's name*

Work Phone*

Area CodePhone Number

Cell Phone*

Area CodePhone Number

E-mail*

Father's Name*

First NameLast Name

Work Phone*

Area CodePhone Number

Cell Phone*

Area CodePhone Number

E-mail*

Parent's Marital Status

Is you child currently attending School?*

Name of School

Are you affiliated with a synagogue? Which?

Are there any allergies or medical issues we should be aware of?*

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 Name

Phone Number*

Area CodePhone Number

Relationship

Emergency Contact 2*

First NameLast Name

Phone Number*

Area CodePhone Number

Relationship

The following people are authorized to pick up my child from My Little Gan during Summer Camp 2018.

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Relationship*

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship

Is child receiving any services?*

Child's t-shirt size

2 week option

3 week option

4 week option

5 week option

Full summer

Schedule Times

9:00-12:15pm9:00-3:00pm

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 NameLast Name

Child's Name

First NameLast Name

Signature - please enter initials

Date

MonthDayYear

PARENTAL CONSENT

By 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 2018 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.

My Little Kaytana Summer Camp Application Form - Summer 2019