Summer Campership Application

This is a lengthy application and cannot be saved once you start entering information. It is highly recommended that you print this application first and enter your answers on a separate document. Then cut and paste your answers into the application. If you have any questions completing this application, contact Lorna at 216.378.3478.

Today's Date *

New or Returning Applicant *

New

Returning

Marital Status *

Single

Married

Divorced

Separated

Widowed

PARENT 1

Parent First Name *

Parent Last Name *

Street Address *

City *

State *

Zip *

Home Phone

Cell Phone *

Email Address *

Place of Birth *

United States

Other

Date of Immigration *

Country of Immigration *

Place of Employment *

Type of Work *

Gross Annual Income *

PARENT 2

Parent 2 First Name *

Parent 2 Last Name *

2 Street Address *

2 City *

2 State *

2 Zip *

2 Home Phone

2 Cell Phone *

2 Email Address *

2 Place of Birth *

United States

Other

2 Date of Immigration *

2 Country of Immigration *

2 Place of Employment *

2 Type of Work *

2 Gross Annual Income *

ABOUT YOUR FAMILY

Has either parent experienced unemployment in the past 3 years? *

Yes

Please explain:

Including yourself, how many individuals currently live in your household? *

Including yourself, list the name of each person living in your household in the space below and their relationship to the head of household: *

Are you currently supporting other family members besides those living in your household? *

Yes

List each family member you support who lives outside your household. For each individual, identify their relationship to the Head of Household and the dollar amount provided by you each MONTH.

Individual's Name

Relationship

Monthly Amount

Individual's Name

Relationship

Monthly Amount

NUMBER OF APPLICANTS

How many children in your household are applying for a campership? *

CHILD 1 APPLICANT

Child 1 First Name *

Child 1 Last Name *

1 Date of Birth *

1 Current Age *

1 Current Grade *

1 School Name *

1 Has this child ever attended camp before? *

Yes

1 Did they attend day camp or overnight camp? *

Day

Overnight

1 What is the name(s) of the camp(s) they attended? *

1 How many years did they attend each camp? *

1 Is there a specific camp you are interested in your child attending? * 1 Is there a specific camp you are interested in your child attending?

1 What was this child's reaction to his/her camp experience? *

1 Are there any special family situations in the past year we should be aware of (divorce or separation, moving, school change, loss of a loved one)? *

1 What three words best describe this child? *

1 What outdoor activities does this child enjoy?

1 How does this child respond to conflict? *

1 How does this child manage stress?

1 Has this child had any disciplinary proceedings at school (including detention, special parent/teacher, guidance counselor or principal meeting, suspension or summer/weekend school)? *

Yes

1 If Yes, please explain.

1 How does this child respond to adult direction? *

1 How does this child interact with their peers?

1 Does this child have:

A lot of friends

A few close friends

No friends

1 Have there been any changes in this child’s school experience since the last report card? *

Yes

1 Please explain. *

1 Is this child currently seeing, or have they ever been, under the care of a therapist, counselor or psychiatrist? *

Yes

1 Please explain the treatment plan length of time and if treatment will continue. during camp

1 Does this child have an IEP or 504 plan for school? *

Yes

1 Please explain.

1 Why do you want this child to attend overnight camp? *

1 Why do you want this child to attend a JEWISH camp? *

1 How does this child feel about going to JEWISH Overnight Camp? *

1 Has this child slept away from home? *

Yes

1 What is the longest number of days this child has slept away from home?

1 What was this child’s experience at the sleepover? *

1 How would you expect this child to respond to being homesick? *

1 What concerns to you have about this child attending Jewish Overnight Camp for 3 or 4 weeks? *

CHILD 2 APPLICANT

Child 2 First Name *

Child 2 Last Name *

2 Date of Birth *

2 Current Age *

2 Current Grade *

2 School Name *

2 Has this child ever attended camp before? *

Yes

2 Did they attend day camp or overnight camp? *

Day

Overnight

2 What is the name(s) of the camp(s) they attended? *

2 How many years did they attend each camp? *

2 Is there a specific camp you are interested in your child attending? * 2 Is there a specific camp you are interested in your child attending?

2 What was this child's reaction to his/her camp experience? *

2 Are there any special family situations in the past year we should be aware of (divorce or separation, moving, school change, loss of a loved one)? *

2 What three words best describe this child? *

2 What outdoor activities does this child enjoy?

2 How does this child respond to conflict? *

2 How does this child manage stress?

2 Has this child had any disciplinary proceedings at school (including detention, special parent/teacher, guidance counselor or principal meeting, suspension or summer/weekend school)? *

Yes

2 If Yes, please explain.

2 How does this child respond to adult direction? *

2 How does this child interact with their peers?

2 Does this child have:

A lot of friends

A few close friends

No friends

2 Have there been any changes in this child’s school experience since the last report card? *

Yes

2 Please explain. *

2 Is this child currently seeing, or have they ever been, under the care of a therapist, counselor or psychiatrist? *

Yes

2 Please explain the treatment plan length of time and if treatment will continue. during camp

2 Does this child have an IEP or 504 plan for school? *

Yes

2 Please explain.

2 Why do you want this child to attend overnight camp? *

2 Why do you want this child to attend a JEWISH camp? *

2 How does this child feel about going to JEWISH Overnight Camp? *

2 Has this child slept away from home? *

Yes

2 What is the longest number of days this child has slept away from home?

2 What was this child’s experience at the sleepover? *

2 How would you expect this child to respond to being homesick? *

2 What concerns to you have about this child attending Jewish Overnight Camp for 3 or 4 weeks? *

CHILD 3 APPLICANT

Child 3 First Name *

Child 3 Last Name *

3 Date of Birth *

3 Current Age *

3 Current Grade *

3 School Name *

3 Has this child ever attended camp before? *

Yes

3 Did they attend day camp or overnight camp? *

Day

Overnight

3 What is the name(s) of the camp(s) they attended? *

3 How many years did they attend each camp? *

3 Is there a specific camp you are interested in your child attending? * 3 Is there a specific camp you are interested in your child attending?

3 What was this child's reaction to his/her camp experience? *

3 Are there any special family situations in the past year we should be aware of (divorce or separation, moving, school change, loss of a loved one)? *

3 What three words best describe this child? *

3 What outdoor activities does this child enjoy?

3 How does this child respond to conflict? *

3 How does this child manage stress?

3 Has this child had any disciplinary proceedings at school (including detention, special parent/teacher, guidance counselor or principal meeting, suspension or summer/weekend school)? *

Yes

3 If Yes, please explain.

3 How does this child respond to adult direction? *

3 How does this child interact with their peers?

3 Does this child have:

A lot of friends

A few close friends

No friends

3 Have there been any changes in this child’s school experience since the last report card? *

Yes

3 Please explain. *

3 Is this child currently seeing, or have they ever been, under the care of a therapist, counselor or psychiatrist? *

Yes

3 Please explain the treatment plan length of time and if treatment will continue. during camp

3 Does this child have an IEP or 504 plan for school? *

Yes

3 Please explain.

3 Why do you want this child to attend overnight camp? *

3 Why do you want this child to attend a JEWISH camp? *

3 How does this child feel about going to JEWISH Overnight Camp? *

3 Has this child slept away from home? *

Yes

3 What is the longest number of days this child has slept away from home?

3 What was this child’s experience at the sleepover? *

3 How would you expect this child to respond to being homesick? *

3 What concerns to you have about this child attending Jewish Overnight Camp for 3 or 4 weeks? *

CHILD 4 APPLICANT

Child 4 First Name *

Child 4 Last Name *

4 Date of Birth *

4 Current Age *

4 Current Grade *

4 School Name *

4 Has this child ever attended camp before? *

Yes

4 Did they attend day camp or overnight camp? *

Day

Overnight

4 What is the name(s) of the camp(s) they attended? *

4 How many years did they attend each camp? *

4 Is there a specific camp you are interested in your child attending? * 4 Is there a specific camp you are interested in your child attending?

4 What was this child's reaction to his/her camp experience? *

4 Are there any special family situations in the past year we should be aware of (divorce or separation, moving, school change, loss of a loved one)? *

4 What three words best describe this child? *

4 What outdoor activities does this child enjoy?

4 How does this child respond to conflict? *

4 How does this child manage stress?

4 Has this child had any disciplinary proceedings at school (including detention, special parent/teacher, guidance counselor or principal meeting, suspension or summer/weekend school)? *

Yes

4 If Yes, please explain.

4 How does this child respond to adult direction? *

4 How does this child interact with their peers?

4 Does this child have:

A lot of friends

A few close friends

No friends

4 Have there been any changes in this child’s school experience since the last report card? *

Yes

4 Please explain. *

4 Is this child currently seeing, or have they ever been, under the care of a therapist, counselor or psychiatrist? *

Yes

4 Please explain the treatment plan length of time and if treatment will continue. during camp

4 Does this child have an IEP or 504 plan for school? *

Yes

4 Please explain.

4 Why do you want this child to attend overnight camp? *

4 Why do you want this child to attend a JEWISH camp? *

4 How does this child feel about going to JEWISH Overnight Camp? *

4 Has this child slept away from home? *

Yes

4 What is the longest number of days this child has slept away from home?

4 What was this child’s experience at the sleepover? *

4 How would you expect this child to respond to being homesick? *

4 What concerns to you have about this child attending Jewish Overnight Camp for 3 or 4 weeks? *

RELIGIOUS BACKGROUND

Which family member(s) of the child(ren) identify as Jewish? *

Mother

Father

Grandmother

Grandfather

Are any other religions practiced in your household? *

Yes

Which religions? *

Are you currently a member of a synagogue? *

Yes

Name of synagogue *

Ahavas Yisroel

Aish Hatorah of Cleveland

B’nai Abraham-Temple B’nai Abraham

B’nai Jeshurun Congregation

Beachwood Kehilla

Beachwood-University Heights Kollel

Beth El – The Heights Synagogue

Beth Israel – The West Temple

Chabad at CWRU

Chabad of Akron

Chabad of Cleveland

Chabad of Cleveland Heights

Chabad of the West Side

Congregation K’Hal Yereim

Congregation Mishkan Or

Congregation Shaarey Tikvah

Congregation Shomre Shabbas

Congregation Zichron Chaim

Downtown Chabad Cleveland

Fromovitz Chabad Center

Green Road Synagogue

Heights Jewish Center Synagogue

Jewish Family Experience (JFX)

Jewish Secular Community of Cleveland

Knesseth Israel Temple (KIT)

Kol HaLev

Oheb Zedek-Cedar Sinai Synagogue

Semach Sedek Synagogue

Solon Chabad

Suburban Temple-Kol Ami

Taylor Road Synagogue

Temple Am Shalom

Temple Beth Shalom

Temple Emanu Elv

Temple Israel (Bath, OH)

Temple Israel Ner Tamid

The Park Synagogue

The Shul

Torah Tzion Kollel

Torah U’Tefilah

Twinsburg Chabad

Young Israel of Greater Cleveland

Zemach Zedek

OtherOther

How often does your family attend synagogue for any purpose? *

Once a week

Once a month

Once a year/Holidays only

Never

Even though you are not a member, do you attend synagogue during the year for any purpose? *

No, do not attend synagogue for any purpose

Once a week

Once a month

Once a year/Holidays only

Name of synagogue *

Ahavas Yisroel

Aish Hatorah of Cleveland

B’nai Abraham-Temple B’nai Abraham

B’nai Jeshurun Congregation

Beachwood Kehilla

Beachwood-University Heights Kollel

Beth El – The Heights Synagogue

Beth Israel – The West Temple

Chabad at CWRU

Chabad of Akron

Chabad of Cleveland

Chabad of Cleveland Heights

Chabad of the West Side

Congregation K’Hal Yereim

Congregation Mishkan Or

Congregation Shaarey Tikvah

Congregation Shomre Shabbas

Congregation Zichron Chaim

Downtown Chabad Cleveland

Fromovitz Chabad Center

Green Road Synagogue

Heights Jewish Center Synagogue

Jewish Family Experience (JFX)

Jewish Secular Community of Cleveland

Knesseth Israel Temple (KIT)

Kol HaLev

Oheb Zedek-Cedar Sinai Synagogue

Semach Sedek Synagogue

Solon Chabad

Suburban Temple-Kol Ami

Taylor Road Synagogue

Temple Am Shalom

Temple Beth Shalom

Temple Emanu Elv

Temple Israel (Bath, OH)

Temple Israel Ner Tamid

The Park Synagogue

The Shul

Torah Tzion Kollel

Torah U’Tefilah

Twinsburg Chabad

Young Israel of Greater Cleveland

Zemach Zedek

OtherOther

What religious holidays do you celebrate at home? *

FINANCIAL INFORMATION

Home Ownership *

Rent

Own

Monthly Rent Amount *

Monthly Mortgage Amount *

Cash on hand *

Monthly Car Payment *

Savings balance *

Monthly Credit Card payments *

Checking Account Balance *

Monthly Medical expenses *

Investments *

Other monthly expenses *

Yes

Monthly Rental Property Income *

Expense

Amount

Monthly Child Support Amount *

Expense

Amount

Other Sources of Income *

Yes

Expense

Amount

Income Source

Amount

Income Source

Amount

Income Source

Amount

Are you divorced or legally separated? *

Yes

Did you receive any child and/or spousal support? *

Yes

Do you receive child support? *

Yes

Monthly Amount

Do you receive spousal support? *

Yes

Monthly Amount

If not, please explain why you do not.

How much in total are you able to financially contribute to your child/children's participation? *

REFERRAL SOURCES

How did you hear about our program? *

Friend/Family

JFSA staff member

JFSA website

Newspaper/Magazine Ad

Flyer

School

OtherOther

Name of Friend or Family Member *

Name of JFSA Staff Member *

Check the box below to indicate your agreement with the following statement: *

I/We acknowledge and confirm that the answers provided in this Application are truthful and accurate.

Check the box below to indicate your agreement with the following statement: *

I/We acknowledge and understand that the JFSA Campership Program may rely on public, non-privileged resources in order to review and process this Application.

Check the box below to indicate your agreement with the following statement: *

I/We acknowledge and understand that filling out and submitting this Application does not guarantee my/our child’s acceptance into the JFSA Campership Program.

Check the box below to indicate your agreement with the following statement: *

I/We grant permission to the JFSA Campership Program to provide, share, disclose, request and receive information to/from any camp that my/our child attended or plans to attend.

UPLOAD YOUR TAX RETURN & REPORT CARDS

Please upload (1) a copy of your most recent federal tax return Form 1040, (2) LAST YEAR’S school report card for each applicant child, and (3) CURRENT report card for each applicant child. *

Maximum file size: 1.54MB

If you are human, leave this field blank.

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UPLOAD YOUR TAX RETURN & REPORT CARDS arrowup6

PARENT 1

PARENT 2

ABOUT YOUR FAMILY

NUMBER OF APPLICANTS

CHILD 1 APPLICANT

CHILD 2 APPLICANT

CHILD 3 APPLICANT

CHILD 4 APPLICANT

RELIGIOUS BACKGROUND

FINANCIAL INFORMATION

REFERRAL SOURCES

UPLOAD YOUR TAX RETURN & REPORT CARDS