Summer Camp Application 2025- Participant

Register my child for SUMMER CAMP 2025:*

Division A (boys & girls ages 5-11) & Teen GirlsTeen Boys - Age 12+

Please Note:

If your child is a new participant at FCLA:

Email jen@fcla.org to schedule an intake meeting and request a new participant application. This form is a supplemental form, specific to the camp for all participants to complete.

Dear Family,

It is with much excitement that we announce

3 WEEKS OF SUMMER CAMP 2025!

This year's camp will take place from

Monday, July 21 - Friday, Aug 8, 2025

GENERAL INFORMATION

Your child must be registered by June 30, 2025. Your child's spot is reserved only when:
- This form is submitted.
- You receive an e-mail confirmation.
- A $50 non-refundable deposit is received.
- SDP Families - All previous balances must be paid in full.

Camp begins at 9:30 am and ends at 3:30 pm (Friday ends at 2:00 pm). Please be prompt for pick-up and drop-off! We go on trips daily and the buses MUST leave by a certain time so we don't miss our trip. If you are running late or your child is sick, please let Racheli know or Rabbi Michy for DivB via text.

Please send a lunch, clearly labeled, in a plastic bag or lunchbox. No paper bags, please. We will provide snacks with a gluten-free option. If your child is on a special diet, please send snacks as well.

For the safety of your child, he/she must wear camp T-shirts each day. Each child will receive one on the first day of camp. Additional t-shirts are available for purchase for $10 each.

Please label ALL of your child’s belongings and send a change of clothing as necessary.

If there is any new information about your child (allergies, behaviors, medical concerns), please let us know in the form below.

FCLA Summer Camp Division A and TEEN GIRLS are located at Friendship Circle, 1952 S. Robertson Blvd. Drop off and pick up will be through the alley in the back ONLY. If your child has difficulty with stairs, please contact us for drop-off alternatives.

To reach us during camp, please call:

Miriam: 323-841-6757 Racheli: 424-274-9192

Rabbi Michy: 323-841-6756

Looking forward to a wonderful summer camp!

The Friendship Circle Team

FCLA Summer Camp Division B are TBD

To reach us during camp, please call:

Rabbi Michy: 323-841-6756

Looking forward to a wonderful summer camp!

The Friendship Circle Team

Child's Name*

First NameLast Name

Child's Age*

Child's Birthday*

Child's Shoe Size*

Mother's Name*

First NameLast Name

Mother's Cell Number*

Area CodePhone Number

Father's Name*

First NameLast Name

Father's Cell Number*

Area CodePhone Number

Best Contact Email*

example@example.com

Camp T-Shirt Size*

Each child will receive one on the first day of camp.

Is your child toilet-trained?*

YesNo

Does your child have allergies?*

yesno

Allergies

Does your child take medication during camp? (No medication may be sent in a campers backpack)*

YesNo

Name of medication?

I allow pictures of my child to be used for publicity ?*

YesNo

Is there any new information we may need to make camp exciting, comfortable, and safe for your child?

Please provide the two best phone numbers for emergency or other necessary contacts in the event that a parent is not available.*

	Name	Relationship	Number
Emergency Contact #1
Emergency Contact #2

Accident: As the parent/legal guardian of {childsName}, I authorize any adult acting on behalf of Friendship Circle Los Angeles to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Friendship Circle personnel will try, but are not required, to communicate with me prior to such treatment.

Trips and Outings: I hereby permit my child/self, {fullName3}to attend and participate in all trips and outings organized as part of the program by Friendship Circle.

Accident & Trip Agreement: Parent/Guardian Signature*

Trip Waiver

This must be submitted for your child to attend the trip.

Click here for Get Air Waiver.

Trip Waiver

This must be submitted for your child to attend the trip.

Click here for Kids Empire Waiver

Trip Waiver

This must be submitted for your child to attend the trip.

Click here for Hapik Waiver

I completed the Waivers.*

Yes

Completed forms and a $50 non-refundable deposit are required by Monday, June 30, 2025 to reserve a spot for your child.

Our Regional Center Vendor Number is HW0425 / Service code 850 / Sub Code SRA: $250 per day.

Friendship Circle Summer Camp is Self Determination friendly.

***No one will be turned away for a lack of funds. For billing matters or scholarship requests please email our billing department/scholarship committee at Billing@fcla.org.

My child will be attending Summer Camp Division A on:*

Week 1 -Monday, July 21- Fri, July 25Week 2 - Monday, July 28- Fri, Aug 1Week 3 - Monday, Aug 4 - Fri, Aug 8

My child will be attending Summer Camp Division B on:*

Week 1 -Monday, July 21- Fri, July 25Week 2 -Monday, July 28 - Fri, Aug 1Week 3 - Monday, Aug 4- Fri, Aug 8

Payment Options

Regional CenterSelf DeterminationPrivate Pay

Which Regional Center?

Name of your child's Service Coordinator

Service Coordinator's Phone Number

Area CodePhone Number

Service Coordinator's Email Address

example@example.com

Which FMS do you use?

FMS Invoicing Code

Which code do we need to use when invoicing your FMS?

Phone Number of FMS

Area CodePhone Number

Self Determination

Deposit Only -$50 Applying for Regional Center Funding

Private Pay

Week 1 - $1,250 personal paymentWeek 2 - $1,250 personal paymentWeek 3 - $1,250 personal paymentDeposit Only -$50 Applying for Scholarship

Additional FCLA Camp T-Shirt, $10 each

1st Additional FCLA Camp T-Shirt Size

2nd Additional FCLA Camp T-Shirt Size

3rd Additional FCLA Camp T-Shirt Size

Sponsorships

Sponsor a child ($3,750)Sponsor a child for a week ($1,250)Sponsor a child for a day ($250)Other

Donation

Make an optional donation to the camp

TOTAL

Total to be charged*

USD

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Payment Notes

SUMMER CAMP IS FULL. Fill out a camp form to be added to the waitlist.

Summer Camp 2025 Application

Accident & Trip Declaration

Payment

Give the gift of camp by sponsoring a child.

Looking forward to an amazing Summer Camp!

** SUMMER CAMP IS FULL. Fill out a camp form to be added to the waitlist. **

Summer Camp 2025 Application

Accident & Trip Declaration

Payment

Give the gift of camp by sponsoring a child.

Looking forward to an amazing Summer Camp!

SUMMER CAMP IS FULL. Fill out a camp form to be added to the waitlist.