My Little Kaytana Summer Camp Application Form - Summer 2024 Child's Name* First Name Last Name Gender* MaleFemale Birth Date* 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Hebrew Name Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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 Married Divorced Separated Other Is your child currently attending school?* Yes No 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 2T 3T 4T 5T 6T 2 week option June 24 - July 5 (deduct $130/80) July 1 - July 12 (deduct $130/80) July 8 - July 19 July 22 - August 2 August 5 -August 16 (deduct $60/35) 3 week option June 24-July 12 (deduct $130/80) July 1-July 19 (deduct $130/80) July 8-July 26 July 15-August 2 July 22- August 9 July 29 -August 16 (deduct $60/35) 4 week option June 24-July 19 (deduct $130/80) July 1-July 26 (deduct $130/80) July 8-August 2 July 15-August 9 July 22 -August 16 (deduct $60/35) 5 week option June 24-July 26 (deduct $130/80) July 1-August 2 (deduct $130/80) July 8-August 9 July 15-August 15 (deduct $60/35) 6 week option June 24-August 2 (Deduct $130/80) July 1-August 9 (deduct $130/80) July 8-August 16 (deduct $60/35) 7 week option June 24-August 9 (Deduct $130/80) July 1-August 16 (deduct $190/115) 8 week option June 24- August 16 Extended Care 3:00-5:00 pm8:00-9:00 am 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 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year 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 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 1 Option 2 Option 3 Should be Empty: This page uses TLS encryption to keep your data secure.