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2021-2022 Chester County Jewish Teen Experience Registration
Chester County Jewish Teen Experience Registration Form
Step
1
of
6
16%
Tuition is $25 per class or 6 classes for $125.
Family &Participant Information
Name of Parent/Guardian #1
*
First
Last
Name of Parent/Guardian #2
First
Last
Participant Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
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California
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Delaware
District of Columbia
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Maine
Maryland
Massachusetts
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New Jersey
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New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Family Email
*
Email - Parent/Guardian #1
Email - Parent/Guardian #2
Please send all correspondence to:
*
Family Email
Parent Guardian #1 Email
Parent/Guardian #2 Email
#1 - Home Phone
*
#1 - Work Phone
#1 - Cell Phone
#2 - Home Phone
#2 - Work Phone
#2 - Cell Phone
How many participants will attend?
1
2
3
Emergency Information
Emergency Contact #1
*
Emergency Contact #2
Phone #1
*
Phone #2
Family Physician
*
Physician Phone
*
Family Dentist
Dentist Phone
Permission for Medical Treatment
I hereby give permission for the synagogue to secure all necessary treatment for the safety and health of my child. I understand that my child will be taken to the nearest hospital or appropriate medical facility as indicated by the emergency. I understand that in case of emergency, every effort will be made to reach me or my designated emergency contact.
Signature
*
Use your mouse or finger to draw your signature below.
Medical Insurance - Name of Carrier
*
Insurance Plan Information
*
Consent Form for Use of Photographs/Videos for Kesher Israel Congregation
*
From time to time, Kesher Israel will publish images or video clips of activities to our KI website, KI Facebook Page, KI ELink, KI Link, and other electronic or printed material that will be accessible to the general public. These activities may be related to Kesher Israel Preschool and Kindergarten, the David Ari and Michael Eric Zukin Religious School, Chester County Hebrew High School, or Youth Groups. No names will be used in captions. You may choose to grant permission for us to publish photographs or video clips of your child. This permission form is valid from: September 1, 2021 – August 31, 2022.
I give permission to Kesher Israel to publish images of my child/children
I DO NOT give permission to Kesher Israel to publish images of my child/children
Child #1
Child #1 - Name
*
First
Last
Child #1 - What are your child's pronouns?
Child #1 Email
Child #1 Cell
Child #1 lives with:
Both parents/guardians
Parent/Guardian #1
Parent/Guardian #2
Child #1 - Birthdate
*
Child #1 - Grade as of September 2021
*
Select
8
9
10
11
12
Child #1 - Name of Secular School
Child #1 - School District
Child #1 - Does your child have any diagnosed learning or emotional issues?
*
Parents are encouraged to meet with Lannie Hulnick to discuss any issues of family concern that may have an impact on their child's school experience. Please call the office at 610-696-7210 for an appointment.
Yes
No
Child #1 - Please describe the diagnosis or issues
Child #1 - Does your child have any medical issues including allergies and medications?
*
Yes
No
Child #1 - Please describe any medical issues including allergies and medications:
Child #1 Has your child received their Covid-19 vaccination?
yes
no
Child #1 - Does your child have any food restrictions?
*
Yes
No
Child #1 - Please provide details of food restrictions:
Child #1 - I give permission for the following medications to be administered to my child:
*
Tylenol
Advil
Motrin
None
Child #1 - I give permission for all information to be shared with my child's teacher.
*
Yes
No
Child #2
Child #2 - Name
First
Last
Child #2 - What are your child's pronouns?
Child #2 Email
Child #2 Cell
Child #2 lives with:
Both parents/guardians
Parent/Guardian #1
Parent/Guardian #2
Child #2 - Birthdate
Child #2 - Grade as of September 2020
Select
8
9
10
11
12
Child #2 - Name of Secular School
Child #2 - School District
Child #2 - Does your child have any diagnosed learning or emotional issues?
Parents are encouraged to meet with Lannie Hulnick to discuss any issues of family concern that may have an impact on their child's school experience. Please call the office at 610-696-7210 for an appointment.
Yes
No
Child #2 - Please describe the diagnosis or issues:
Child #2 - Does your child have any medical issues including allergies and medications?
Yes
No
Child #2 - Please describe any medical issues including allergies and medications:
Child #2 Has your child received their Covid-19 vaccination?
yes
no
Child #2 - Does your child have any food restrictions?
Yes
No
Child #2 - Please provide details of food restrictions:
Child #2 - I give permission for the following medications to be administered to my child:
Tylenol
Advil
Motrin
None
Child #2 I give permission for all information to be shared with my child's teacher.
Yes
No
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Chester County Jewish Teen Experience
2021-2022 Chester County Jewish Teen Experience Registration