Online Application Family Name(Required) First Phone(Required)Email(Required) Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Name(Required) First Father's Cell Phone(Required)Father's Occupation/Employer(Required) Father's Work Phone(Required)Mother's Name(Required) First Mother's Cell Phone(Required)Mother's Occupation/Employer(Required) Mother's Work Phone(Required)Emergency Contact Name(Required) First Emergency Contact Relationship(Required) Emergency Contact Phone Number(Required)Camper 1Name(Required) Current School(Required) School Attending Next Year(Required) Camper's Date of Birth(Required) MM slash DD slash YYYY Present Grade(Required)Please SelectUPKPre-1A12345678Gender(Required)Please SelectBoyGirlSession(Required)Please Select1st Half2nd HalfFull SummerIf possible place my child with: (provide 1-2 full names) Does you child have IEP or 504 Plan?(Required)Please selectYesNoWhat is the classification?(Required) Does your child have/has had any of the following services:(Required) Occupational therapy Physical Therapy Speech counseling (psychologist, psychiatrist, social worker, school counselor, etc) None Please specify why he/she received these services(Required) Does your child have SEIT or SETSS?(Required)Please selectYesNoHow many hours a week?(Required) Is your child eligibile for his/her services 10 months or 12 months a year?(Required)Please select10 months12 monthsDoes your child have/has a shadow?(Required)Please selectYesNoDoes your child have any difficulties that may make a camp setting challenging for him/her? Please specify(Required) Camper 2Name Current School School Attending Next Year Camper's Date of Birth MM slash DD slash YYYY Present GradePlease SelectUPKPre-1A12345678GenderPlease SelectBoyGirlSessionPlease Select1st Half2nd HalfFull SummerIf possible place my child with: (provide 1-2 full names) Does you child have IEP or 504 Plan?Please selectYesNoWhat is the classification? Does your child have/has had any of the following services: Occupational therapy Physical Therapy Speech counseling (psychologist, psychiatrist, social worker, school counselor, etc) None Please specify why he/she received these services Does your child have SEIT or SETSS?Please selectYesNoHow many hours a week? Is your child eligibile for his/her services 10 months or 12 months a year?Please select10 months12 monthsDoes your child have/has a shadow?Please selectYesNoDoes your child have any difficulties that may make a camp setting challenging for him/her? Please specify Camper 3Name Current School School Attending Next Year Camper's Date of Birth MM slash DD slash YYYY Present GradePlease SelectUPKPre-1A12345678GenderPlease SelectBoyGirlSessionPlease Select1st Half2nd HalfFull SummerIf possible place my child with: (provide 1-2 full names) Does you child have IEP or 504 Plan?Please selectYesNoWhat is the classification? Does your child have/has had any of the following services: Occupational therapy Physical Therapy Speech counseling (psychologist, psychiatrist, social worker, school counselor, etc) None Please specify why he/she received these services Does your child have SEIT or SETSS?Please selectYesNoHow many hours a week? Is your child eligibile for his/her services 10 months or 12 months a year?Please select10 months12 monthsDoes your child have/has a shadow?Please selectYesNoDoes your child have any difficulties that may make a camp setting challenging for him/her? Please specify Camper 4Name School Attending Next Year Current School Camper's Date of Birth MM slash DD slash YYYY Present GradePlease SelectUPKPre-1A12345678GenderPlease SelectBoyGirlSessionPlease Select1st Half2nd HalfFull SummerIf possible place my child with: (provide 1-2 full names) Does you child have IEP or 504 Plan?Please selectYesNoWhat is the classification? Does your child have/has had any of the following services: Occupational therapy Physical Therapy Speech counseling (psychologist, psychiatrist, social worker, school counselor, etc) None Please specify why he/she received these services Does your child have SEIT or SETSS?Please selectYesNoHow many hours a week? Is your child eligibile for his/her services 10 months or 12 months a year?Please select10 months12 monthsDoes your child have/has a shadow?Please selectYesNoDoes your child have any difficulties that may make a camp setting challenging for him/her? Please specify *Camp fee schedule includes busing for campers in the Queens area only. There is a minimum registration of 2 weeks per camper at a rate of $900 for younger child or $1000 for older child per 2 weeks. Complete this application form in full and return with a non refundable and non transferable Registration Fee of $500 per camper! Deposit is not refundable for any reason including but not limited to: Cancellation by either the Applicant or the Camp, closure due to COVID-19 or any other natural or un-natural causes. The $500 deposit/registration fee is non refundable and non transferable for any reason Applications will not be processed without the Registration Fee and a signed application. Post-dated checks WILL NOT be accepted. We are not responsible for any checks in our possession that was deposited earlier than the date on the check. All associated fees will be applied to the customer. Remaining balance is due in full and must be paid by May 1st; after May 1st all new applications must include full payment. Any payment made within 10 business days before the start of camp must be made in cash as there is no longer time for checks to clear. There is a $40 fee for any bounced check/eCheck. There is no reduction or refund due to absence, illness or withdrawals. Any additional children or any extensions will be charged based on the payment scale at the time of addition or extension. Additionally, after April 1st any changes made concerning camp dates are subject to a $100 service fee. There will be a $150 per half ($300 for full summer) surcharge for meals that will be waived if a summer lunch form is completed by June 1st, irrespective of qualification. The Board of Health requires that a current medical check up form for each camper be on file with the camp office prior to the start of camp. Completed medical forms must be submitted prior to June 1st. Chazak Day Camp reserves the right to use all pictures and/or videos taken during the summer for publicity purposes. Any items left in camp at dismissal on the last day of camp are considered hefker. In the event of a cancellation, the following procedures are in effect: Before May 1st, all camp fees will be refundable except for the $500 Registration Fee per camper. After May 1st, no refunds will be made. I hereby authorize the Chazak Day Camp staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I hereby authorize my Child's school to release my child's USDA eligibility status to Chazak Day Camp.Medical InformationPhysician(Required) Phone(Required)May your child be given Tylenol or equivalent analgesic medication?(Required)YesNoPlease indicate whether your child has any allergies or takes any medications:(Required) By selecting the "Register" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "Register" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforce ability of your E-Signature. Signature(Required) You MUST include the name of your child(ren) in the body of the payment so we can properly mark them down as being paid, if you do not include the names we may not be able to associate the payment with your account!Payment Method(Required)eCheck/ACHeCheck/ACH InfomationBy using eCHeck/ACH you agree to be charged automatically each month until your balance has been paid completely. You will be charged a deposit now of $500 per camper which is non refundable. The balance of your payment may be done via Quickpay or Venmo or Cash or Check.Deposit Camper #1(Required) Price: Deposit Camper #2(Required) Price: Deposit Camper #3(Required) Price: Deposit Camper #4(Required) Price: eCheck/ACH Fee(Required) Price: $0.00 Total ACH(Required) Account Number SelectSavingsChecking Account Type Routing Number Account Holder Name Please make sure to enter the information correctly or the check will bounce.