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Camp Scholarship Application
Summer 2024
Primary Contact
First Name
*
Last Name
*
Phone Number
*
Email
*
Street Address
*
City
*
Postal Code
*
State/Province
*
Relationship to child
*
- Select -
Mother
Father
Activity Subject
Secondary Contact
First Name
*
Last Name
*
Gender
- None -
Female
Male
Phone Number
*
Email
*
Relationship to child
*
- Select -
Mother
Father
Grandparent
Other
Share address
Same Address?
Street Address
*
City
*
Postal Code
*
State/Province
*
Relationship to Father Relationship Type(s)
Spouse of
Partner of
Ex-Spouse of
Other relation to
How many kids do you want to apply for?
*
1
2
3
4
Child 1
First Name
*
Last Name
*
Gender
*
- Select -
Female
Male
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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
Year
Year
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Grade in the coming year
*
- Select -
Mini Gan
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
Weeks of camp the child will attend
*
Week 1 (June 24-28)
Week 2 (July 1-5)
Week 3 (July 8-12)
Week 4 (July 15-19)
Week 5 (July 22-26)
Week 6 (July 29-August 2)
Does the child need Early/late stay?
Does the child need Early/late stay?
Select Weeks for Early stay
Extra $50/week
Early Stay Week 1
Early Stay Week 2
Early Stay Week 3
Early Stay Week 4
Early Stay Week 5
Early Stay Week 6
Select Weeks for Late stay
Extra $70/week
Late Stay Week 1
Late Stay Week 2
Late Stay Week 3
Late Stay Week 4
Late Stay Week 5
Late Stay Week 6
School attending
*
Does your child have an IEP?
*
Yes
No
We're here to make your child's time special. Let us know anything we should be aware of, whether it's sensory preferences, ADHD, a sensitivity, or anything else.
With your Camp Gan Israel registration, your child will receive a free CGI T-shirt. What size would be best?
*
- Select -
Child - XS
Child - S
Child - M
Child - L
Adult - S
Adult - M
Adult - L
Adult - XL
Medical History
Does the child have a chronic illness?
*
Yes
No
receiving medication on a regular basis?
*
Yes
No
Does the child have allergies?
*
Yes
No
Chronic illness detailes
*
Medication details
*
Allergy details
*
Please list any information that may directly affect the safe care or medical treatment of your child
Relationship Type(s) 2
Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of
Child 2
First Name
*
Last Name
*
Gender
*
- Select -
Female
Male
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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
Year
Year
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Grade in the coming year
*
- Select -
Mini Gan
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
Weeks of camp the child will attend
*
Week 1 (June 24-28)
Week 2 (July 1-5)
Week 3 (July 8-12)
Week 4 (July 15-19)
Week 5 (July 22-26)
Week 6 (July 29-August 2)
Does the child need Early/late stay?
Does the child need Early/late stay?
Select Weeks for Early stay
Extra $50/week
Early Stay Week 1
Early Stay Week 2
Early Stay Week 3
Early Stay Week 4
Early Stay Week 5
Early Stay Week 6
Select Weeks for Late stay
Extra $70/week
Late Stay Week 1
Late Stay Week 2
Late Stay Week 3
Late Stay Week 4
Late Stay Week 5
Late Stay Week 6
School attending
*
Does your child have an IEP?
*
Yes
No
We're here to make your child's time special. Let us know anything we should be aware of medically or otherwise, such as sensory preferences, ADHD, a sensitivity, or anything else.
With your Camp Gan Israel registration, your child will receive a free CGI T-shirt. What size would be best?
*
- Select -
Child - XS
Child - S
Child - M
Child - L
Adult - S
Adult - M
Adult - L
Adult - XL
Medical History
Does the child have a chronic illness?
*
Yes
No
receiving medication on a regular basis?
*
Yes
No
Does the child have allergies?
*
Yes
No
Chronic illness detailes
*
Medication details
*
Allergy details
*
Please list any information that may directly affect the safe care or medical treatment of your child
Relationship Type(s) 2
Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of
Child 3
First Name
*
Last Name
*
Gender
*
- Select -
Female
Male
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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
Year
Year
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Grade in the coming year
*
- Select -
Mini Gan
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
Weeks of camp the child will attend
*
Week 1 (June 24-28)
Week 2 (July 1-5)
Week 3 (July 8-12)
Week 4 (July 15-19)
Week 5 (July 22-26)
Week 6 (July 29-August 2)
Does the child need Early/late stay?
Does the child need Early/late stay?
Select Weeks for Early stay
Extra $50/week
Early Stay Week 1
Early Stay Week 2
Early Stay Week 3
Early Stay Week 4
Early Stay Week 5
Early Stay Week 6
Select Weeks for Late stay
Extra $70/week
Late Stay Week 1
Late Stay Week 2
Late Stay Week 3
Late Stay Week 4
Late Stay Week 5
Late Stay Week 6
School attending
*
Does your child have an IEP?
*
Yes
No
We're here to make your child's time special. Let us know anything we should be aware of medically or otherwise, such as sensory preferences, ADHD, a sensitivity, or anything else.
With your Camp Gan Israel registration, your child will receive a free CGI T-shirt. What size would be best?
*
- Select -
Child - XS
Child - S
Child - M
Child - L
Adult - S
Adult - M
Adult - L
Adult - XL
Medical History
Does the child have a chronic illness?
*
Yes
No
receiving medication on a regular basis?
*
Yes
No
Does the child have allergies?
*
Yes
No
Chronic illness detailes
*
Medication details
*
Allergy details
*
Please list any information that may directly affect the safe care or medical treatment of your child
Relationship Type(s) 2
Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of
Child 4
First Name
*
Last Name
*
Gender
*
- Select -
Female
Male
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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
Year
Year
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Grade in the coming year
*
- Select -
Mini Gan
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
Weeks of camp the child will attend
*
Week 1 (June 24-28)
Week 2 (July 1-5)
Week 3 (July 8-12)
Week 4 (July 15-19)
Week 5 (July 22-26)
Week 6 (July 29-August 2)
Does the child need Early/late stay?
Does the child need Early/late stay?
Select Weeks for Early stay
Extra $50/week
Early Stay Week 1
Early Stay Week 2
Early Stay Week 3
Early Stay Week 4
Early Stay Week 5
Early Stay Week 6
Select Weeks for Late stay
Extra $70/week
Late Stay Week 1
Late Stay Week 2
Late Stay Week 3
Late Stay Week 4
Late Stay Week 5
Late Stay Week 6
School attending
*
Does your child have an IEP?
*
Yes
No
We're here to make your child's time special. Let us know anything we should be aware of medically or otherwise, such as sensory preferences, ADHD, a sensitivity, or anything else.
With your Camp Gan Israel registration, your child will receive a free CGI T-shirt. What size would be best?
*
- Select -
Child - XS
Child - S
Child - M
Child - L
Adult - S
Adult - M
Adult - L
Adult - XL
Medical History
Does the child have a chronic illness?
*
Yes
No
receiving medication on a regular basis?
*
Yes
No
Does the child have allergies?
*
Yes
No
Chronic illness detailes
*
Medication details
*
Allergy details
*
Please list any information that may directly affect the safe care or medical treatment of your child
Relationship Type(s) 2
Child of
Parent of
Spouse (primary contact)
Spouse of
Partner of
Sibling of
Supervised by
Supervisor
Yahrzeit observed by
Yahrzeit observed in memory of
Nephew/Niece of
Uncle/Aunt of
Grandchild of
Grandparent of
Cousin of
Child in law of
Parent in law of
Sibling in law of
Step child of
Step parent of
Great Nephew/Niece of
Great Uncle/Aunt of
Ex-Spouse of
Friend of
Other relation to
Emergency Contact is
Emergency Contact of
Is Spouse of
Authorization for Emergency Medical Care
Doctor’s Full Name
*
Office Phone Number
*
Preferred Hospital
*
In the event my child becomes ill or is injured at school or while under the supervision of the school, I hereby authorize any employee or representative of Gan Gani Preschool to obtain medical aid for my child. I have been advised by the school that it will exercise such authorization when I cannot be contacted in time. I acknowledge that charges for such medical care will be my responsibility and not that of Gan Gani Preschool.
Signature of Parent
*
Date
*
Month
Month
Apr
Day
Day
27
Year
Year
2024
Financial Information
Activity Subject
Single-parent household?
- None -
Yes
No
Your present gross income level is:
- None -
Under $20,000
$20,001 to $25,000
$25,001 to $30,000
$30,001 to $35,000
$35,001 to $40,000
$40,001 to $45,000
$45,001 to $50,000
Above $50,000
Do you
- None -
Own
Rent
Monthly rent or mortgage payments
Father: employer’s Name, Address and Telephone number
Mother: employer’s Name, Address and Telephone number
Other Information that may be of help
Is there a volunteer service that you can provide to the Camp Gan Israel or Chabad Center?
Please State the reason(s) why you feel a scholarship should be granted in your situation
How much can you afford to pay per week for your child(ren) to attend Camp Gan Israel
How much can you afford to pay for the whole summer
Discount code
Registration fee
$
$75/child
Contribution Source
I want to pay security fee now ($55/child)
I want to pay the security fee now ($55/child)
You can pay now or later with your payment plan
Security fee
$
Authorization_1
*
I hereby give permission for my child to participate in all camp activities. In addition, I give Camp Gan Israel permission (a) to transport campers in connection with activities (b) to render necessary first aid or to arrange care by medical personnel, if deemed necessary; (c) to use photographs and videos and names of campers in printed material and websites associated with CGI; (d) I indemnify and hold harmless Camp Gan Israel from any liability or claim for any loss, injury, damage or expense resulting or arising from my child's participation in camp activities. In addition, I acknowledge that the camp administration reserves the right to reconsider the enrollment of any camper if we feel the child's needs or level of functioning or behavior cannot be accommodated, or if the child's conduct limits his or her ability to participate in, or to benefit fully from, the program and activities at CGI. In addition, I acknowledge that I have read and accept the financial obligations and the refund policy as stated in the application form.
Yes *
Chabad Center for Jewish Life & Learning
info@chabadsa.com
|
210-764-0300
|
14535 Blanco Rd.
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