Youth Groups @EBJC Registration 2017-2018
All information will remain confidential and be used only by the EBJC administration team. Yearly dues are:
USY (9th-12th grades): $75 EBJC members; $100 nonmembers
Kadima (6th-8th grades): $65 EBJC members; $80 nonmembers
Chaverim (4th-5th grades): $50 EBJC members; $60 nonmembers
Family last name
Your answer
Student 1 name
Your answer
Student 1 Hebrew name (in Hebrew or transliteration)
Your answer
Student 1 Birth Date
MM
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DD
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YYYY
Student 1 Email
Your answer
Student 1 Cell Phone
Your answer
Student 2 name
Your answer
Student 2 Hebrew name (in Hebrew or transliteration)
Your answer
Student 2 Birth Date
MM
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DD
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YYYY
Student 2 Email
Your answer
Student 2 Cell Phone
Your answer
Student 3 name
Your answer
Student 3 Hebrew name (in Hebrew or transliteration)
Your answer
Student 3 Birth Date
MM
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DD
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YYYY
Student 3 Email
Your answer
Student 3 Cell Phone
Your answer
Please list any allergies with name of student - food, medication, environment, etc. If none, write "none."
Your answer
Describe typical allergic reaction and treatment. If none, write "none."
Your answer
Students' primary street 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 name (other than parent)
Your answer
Emergency contact relationship to child
Your answer
Emergency contact phone number
Your answer
Students reside with
Name of school Student 1 will attend 2017-18
Your answer
Name of school Student 2 will attend 2017-18
Your answer
Name of school Student 3 will attend 2017-18
Your answer
Student 1 date of birth
MM
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DD
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YYYY
Student 2 date of birth
MM
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DD
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YYYY
Student 3 date of birth
MM
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DD
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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 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 1 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 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 1 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
Health Insurance - name of insured
Your answer
Relation of insured to students
Your answer
Insurance company
Your answer
Policy number
Your answer
Group number
Your answer
Insurance company address and phone number
Your answer
List ALL medications taken routinely by students, including prescription, over-the-counter, and non-prescription. If none, write "none."
Your answer
Describe dosages and times taken for each medication listed above. If none, write "none."
Your answer
Is Student 1 fully vaccinated? If no, please explain.
Your answer
Is Student 2 fully vaccinated? If no, please explain.
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
Enroll Student 1 in the following youth group:
Required
Enroll Student 2 in the following youth group:
Enroll Student 3 in the following youth group:
Synagogue the family belongs to (if unaffiliated, write "None").
Your answer
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