CTI's Shalom Playgroup (drop off program) Registration Form
Once a week
Fridays, from September 2018 - December 2018
9am - 12noon (a light lunch will be provided)
Ages: 2-3 years

Contact: Lisa Aamodt morahlisaa@gmail.com 516-676-5080

Please make sure to come into the office to make your payment and sign your form!
Looking forward to the new year!

Child's Name
Your answer
Child's Hebrew Name
Your answer
Gender
Child's Birthday
Your answer
Address
Your answer
City
Your answer
Zip Code
Your answer
Home Phone
Your answer
Parent Email
Your answer
Parent 1 Name
Your answer
Parent 1 Contact
Your answer
Parent 2 Name
Your answer
Parent 2 Contact
Your answer
Allergies or Medical Conditions
Your answer
Epipen
If I am not available and a medical emergency arises, the supervising teacher has my permission to seek medical help with:
Your answer
Emergency Contact 1
Your answer
Emergency Contact 2
Your answer
I give permission for photos to be taken of my child and used by the synagogue.
Your answer
Would you like to receive text messages regarding the program?
Is there anything else you would like us to know about your child?
Your answer
I am interested in volunteering to read stories and participate in the program with my child.
Submit
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