JYC 2020-2021 Registration
Parent Name *
Number of Children Registering *
Child #1 Name *
Is this student a new or returning student? *
Child's Gender *
Child's Date of Birth *
MM
/
DD
/
YYYY
Grade for the 2020-2021 School Year *
Street Address *
City *
State *
Zip *
Home Phone *
Parent 1 Name *
Parent 1 Hebrew Name *
Parent 1 Email *
Parent 1 Cell Phone *
Parent 2 Name
Parent 2 Hebrew Name
Parent 2 Email
Parent 2 Cell Phone
Parent 1 Occupation *
Parent 2 Occupation
Grandparent's Names
Grandparent's Emails
Child's Current School
Reference Name and Number at Your Child's Current School *
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Email *
Relationship to Student *
Physician's Name *
Physician's Phone *
Health Insurance Carrier *
Family Synagogue *
Do you have another child you would like to register for JYC at this time? *
Child #2 Name
Child #2 Gender
Clear selection
Child #2 Date of Birth
MM
/
DD
/
YYYY
Child #2 Grade for the 2020-2021 School Year
Clear selection
Child #2 School
Child #2 Reference Name and Phone *
Child #3 Name
Child #3 Gender
Clear selection
Child #3 Date of Birth
MM
/
DD
/
YYYY
Child #3 Grade for the 2020-2021 School Year
Clear selection
Current School
Reference Name and Phone Number
Do any of your children receive any special services at secular school, such as special education classes, resource room pull-out programs, or any other services? *
If yes, please specify. (This will be kept 100% confidential and will help us teach your child to the best we can.)
Please provide the service coordinator's contact info (email and phone) so we could ensure we establish the necessary supports.  
Did someone recommend JYC to you? If so, please provide their name.
By checking this box we understand that it is the practice of the School to use photographs, recordings, videos and quotations of students in its publications and in other selected media, for the purpose of promoting the school and its programs. We agree that as parents, we give permission to use such photographs, video, recordings, and quoted material in JYC  publications or other selected media unless we specifically notify the school in writing to the contrary. *
Required
Parents Signature *
Date *
MM
/
DD
/
YYYY
Comments
Thank You!
We look forward to seeing you this Fall!
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy