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Religious School
Religious School Registration Form
Child Information
Child's First Name
(Required)
Child's Last Name
(Required)
Child's Hebrew Name
Child's Birthdate
(Required)
Child's Grade as of 9/24
(Required)
Child's School
(Required)
Child's Primary Mailing Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
If your child does not have a Hebrew name, do you need help choosing them?
Yes
No
Does your child have any allergies or other medical condition of which we should be aware?
(Required)
Yes
No
If yes: Please describe them and indicate special precautions or care needed (i.e., Epi-pen).
Medical Condition Consent
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Congregation Emanu-El of Westchester to secure medical treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, the staff of Congregation Emanu-El will try, but are not required, to communicate with me prior to such treatment.
Yes, I/we consent
Does your child have any emotional or behavioral needs of which we should be aware?
(Required)
Yes
No
If yes: please describe the emotional or behavioral needs.
Does your child have any learning needs of which we should be aware?
(Required)
Yes
No
If yes: does your child currently have an IEP or 504 plan?
Yes
No
If yes: please describe the learning needs.
Emergency Contact Information
Emergency Contact Name
(Required)
Emergency Contact Email
(Required)
Emergency Contact Cell Phone
(Required)
Emergency Contact – Relationship to Child
(Required)
Parent Information
Parent #1 – Name
(Required)
Parent #2 – Name
Parent #1 – Email
(Required)
Parent #2 – Email
Parent #1 – Cell Phone
(Required)
Parent #2 – Cell Phone
Parent #1 – Home Phone
Parent #2 – Home Phone
Information regarding the Religious School and your child’s progress should be sent to
(Required)
Parent #1
Parent #2
Both parents
Photo Consent
(Required)
I consent to the use of photographs and/or videos taken of my child during the course of the school year for publicity, promotional, and or/educational purposes (including being posted on our private social media accounts.
Yes, I consent
No, I do not consent
CAPTCHA
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