Kesher @EBJC Registration 2017-2018
All information will remain confidential and be used only by the Kesher administration team.
Student 1 Last Name: *
Your answer
Student 1 First Name *
Your answer
Student 1 Hebrew Name (in Hebrew or transliteration) *
Your answer
Student 2 Name
Your answer
Student 2 Hebrew Name (in Hebrew or transliteration)
Your answer
Student 3 name
Your answer
Student 3 Hebrew name (in Hebrew or transliteration)
Your answer
Please list any Allergies *
Your answer
Reactions to allergies: *
Your answer
Student Home address *
Your answer
City *
Your answer
Zip code *
Your answer
Student Home phone: *
Your answer
Parent 1 Name: *
Your answer
Parent 1 email: *
Your answer
Parent 1 address if different from student
Your answer
Parent 1 cell phone: *
Your answer
Parent 2 Name:
Your answer
Parent 2 email:
Your answer
Parent 2 address if different from student
Your answer
Parent 2 Cell phone:
Your answer
Emergency contact (other than parent): *
Your answer
Emergency Contact relationship to Student: *
Your answer
Emergency contact phone number: *
Your answer
Students reside with *
Name of school Student 1 will attend 2017-18 and school grade *
Your answer
Name of school Student 2 will attend 2017-18 and school grade
Your answer
Name of school Student 3 will attend 2017-18 and school grade
Your answer
Student 1 date of birth *
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YYYY
Student 2 date of birth
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DD
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YYYY
Student 3 date of birth
MM
/
DD
/
YYYY
Parent 1 Occupation *
Your answer
Parent 1 Place of work (name and address) *
Your answer
Parent 2 occupation
Your answer
Parent 2 place of work (name and address)
Your answer
INTERNAL: Photographs and video images of students in the Kesher @EBJC education and youth programs are routinely taken for the purpose of celebrating student achievement and sharing educational programs with the community. Photographs may be used throughout the synagogue, and/or posted on websites associated with EBJC. Video footage may also be posted on sites associated with EBJC. Please check one box below. *
We are asking for permission to use students' photo/video images to be published on INTERNAL websites associated with EBJC (such as EBJC facebook page), and on EBJC publications (such as the Recorder).
Required
EXTERNAL: Photographs and video images of students in the Kesher @EBJC education and youth programs are routinely taken for the purpose of celebrating student achievement and sharing educational programs with the community. Photographs may be submitted to area newspapers. Video footage may be submitted to area news outlets that cover special events that occur in the area or posted to websites. Please check one box below. *
We are asking for permission to use any photo/video image that includes these students to be shared with EXTERNAL media outlets, including newspapers and television stations. Under no circumstances will EBJC release personally identifiable information with such images other than the child's name, age, and/or grade.
Required
Insured's name: *
Your answer
Insured Relationship to child *
Your answer
Insurance *
Your answer
Insurance number *
Your answer
Group Number *
Your answer
Insurance address *
Your answer
Does Student 1 take any medications? *
Your answer
Does Student 2 Take any medications? *
Your answer
Is Student 1 fully vaccinated? If no, please explain. *
Your answer
Is Student 2 fully vaccinated? If no, please
Your answer
Is Student 3 fully vaccinated? If no, please explain.
Your answer
Please check all that apply: Student 1 *
Required
Please check all that apply: Student 2
Please check all that apply: Student 3
Please explain in detail any answers checked above. *
Your answer
PARENT'S AUTHORIZATION AND PERMISSION TO PROVIDE EMERGENCY CARE: My typed name below indicates my agreement with the following: To the best of my knowledge, the medical history is correct and complete. I know of no reason to restrict the participant's activity and hereby give my permission for participation in all activities except as specifically noted herein. In the event that I cannot be reached in an emergency, I hereby give permission to the medical personnel selected by the East Brunswick Jewish Center to order x-rays, routine tests, treatment, and transportation for my child. I also hereby give permission to the physician selected by EBJC to secure and administer treatment, including hospitalization, for the persons named above. *
Your answer
Student 1 registration *
Required
Enroll Student 1 in the following youth group: *
Required
Student 2 registration
Enroll Student 2 in the following youth group:
Student 3 registration
Enroll Student 3 in the following youth group:
Synogogue Family belongs to: *
Your answer
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