Camper Application - Chabad Lubavitch of Staten Island

- Please fill out one application per child.
- Camp will be in session Wednesday June 24-Wednesday August 29 (No Camp July 23/9 Av)
- First Session June 24-July 22
- Second Session July 23-August 19
- Mini Gan YISI is for children entering 3k-4k in September 2026 (MUST be toilet trained)
- Gan YISI is for children entering Pre 1A-3rd Grade in September 2026
- Fees for Member Families enrolling in Mini Gan YISI & Gan YISI
  - Full Summer Season $2200
  - One Session $1250
- Fees for Non-Member Familues enrolling in Mini Gan YISI & Gan YISI
  - Full Summer Season $2500
  - One Session 1400
- We are excited about our enhanced CIT program for children entering Grade 4+.
- Fees for CIT program Member Families
  - Full Summer Season $2400
  - One Session $1300
- Fees for CIT program Non-Member Families
  - Full Summer Season $2600
  - One Session $1450
- Please email office@yisi.org to inquire about becoming a member family today!
- A $100 sibling discount will apply to non member enrollments of two full summer sessions.
- A $100 late fee will be applied to all registration made after May 26.
- Information about camp lunch will be sent out soon IYH.
- Please reach out to daycamp@yisi.org with any questions.
1. Child/ren’s Information
Child Name*
First Name Middle Name Last Name
Birth Date*

Month Day Year
Gender*

MaleFemale
Division*

Mini Gan YISI (Entering 3k+4K)Gan YISI (Entering Pre1A-3rd Grade)Mini Tweens (Entering 4th Grade +)
Grade entering Sep 2025*

3K(Must be toilet trained)4KPre 1a/ PrimerFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth Grade
School Attending*
Sessions*

Non Member Entire Summer $2500Non Member Session 1 $1400Non Member Session 2 $1400Member Entire Summer $2200Member Session One $1250Member Session Two $1250Mini Tweens Member Full SummerMini Tweens Member Session TwoMini Tweens Member Session OneMini Tweens Non Member Full SummerMini Tweens Non Member Session OneMini Tweens Non Member Session Two
Mini Tweens Session*

Entire Summer $2400Session One $1300Session Two $1300Member Entire Summer $2200Member Session One $1200Member Session Two $1200
T Shirt Size*
Are you interested in Extended Care?*
2. Parent information
Phone Number*

Area Code Phone Number

Address*

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

Mother's info*
First Name Last Name
Occupation*
Work Phone*

Area Code Phone Number
E-mail* Primary email
Cell Phone*

Area Code Phone Number
Father's info*
First Name Last Name
Occupation*
Work Phone*

Area Code Phone Number
E-mail*
Cell Phone*

Area Code Phone Number
YISI Members*

YesNo
Marital Status*
How did you hear of us?
3. Emergency & Special Needs Information
Emergency Contact (OTHER THAN PARENT)*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
In order to create an effective and positive camp environment for everyone, please provide the following information for your child. All information will be handled with care and held in confidence
Does your child have an IEP or 504 Plan?*

YesNo
Please email your child's IEP or 504 to the camp office
Does your child receive any other services? *

YesNo
If Yes, please specify
Other special considerations (Allergies, medical challenges, behavioral challenges etc)*
4. Payment Information
A 25% deposit is required at registration. All balances must be paid in full by 6/19. The camp office will be reaching out shortly after registraiton with an invoice and to set up a payment plan for any balances due.
Lice Check*

I Agree to a $10 Lice check per child (To be charged separately)
Total

$0.00

I would like to pay today:Full amount25% minimum: $0.00 $

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Please contact the Camp office for special requests.
- I grant permission for my child to participate in all camp activities, including swimming and trips away from camp grounds (dates and destinations to be provided at a later date).
- I understand that if my application is not filled out completely or the required payments are not enclosed, my application will not be processed and will be returned.
- I agree to disclose any behavioral help my child receives during the school year, to ensure that Camp has the ability to accommodate my child's needs.
- I agree that my child may be photographed, and their pictures may be used in future camp promotional materials, including, but not limited to the brochure and the Gan YISI website.
- No camper will be permitted into camp without all forms completed (including medical and application) and all financial obligations satisfied.
- Gan YISI is not responsible for personal property brought to camp.
- If the Camper’s conduct is harmful to the best interests of Gan YISI Day Camp, the Camper may be dismissed at the sole discretion of the Director with no refund nor reduction of fee.
- I will settle my financial obligations to camp before camp starts
Should be Empty:

1. Child/ren’s Information

2. Parent information

3. Emergency & Special Needs Information

In order to create an effective and positive camp environment for everyone, please provide the following information for your child. All information will be handled with care and held in confidence

4. Payment Information