Child's Information
Child's First Name:
Child's FULL Jewish Name:
Child's Last Name:
Gender:
Date of Birth *mm/dd/yyyy
Home Phone Number:
Street Address
City
State
Zip Code
Your Email
I would like to register my child for:
Days & Tuition:
January 5, 2022 - March 16, 2022
WEDNESDAYS: 9:30 am - 11:30 am - $500
General Information
Known food allergies:
If applicable, please list
1) All food allergies
2) Symptoms
3) Treatment
What is your current synagogue affiliation?
Have been there any adoptions or conversions in the family? Please explain.
Does your child have siblings? Please list all siblings, their age and school they attend.
What is your child's previous school, group or camp experience (if any)?
Does your child receive any special services? i.e.: Speech, OT, PT, SEIT, etc. Please be specific.
Are there any special circumstances which we should know?
Parent's Information
Father
First Name:
Last Name:
Email:
Occupation:
Business Phone:
Cell Phone:
Mother
First Name:
Last Name:
Email:
Occupation:
Business Phone:
Cell Phone:
I ALLOW my child's photograph to be used for promotional materials, website and Facebook page.
I DO NOT allow my child's photograph to be used for promotional materials, website and Facebook page.
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