2021-2022 Chester County Jewish Teen Experience Registration

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 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?

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

Tuition is $25 per class or 6 classes for $125.