11th Grade Teen Torah Registration

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11th Grade Teen Torah

Please complete this enrollment form to enroll your child in Teen Torah. Should you have any questions or concerns, please contact the Religious School Office, 305) 935-1046.

PARENT/CARE TAKER INFORMATION

Child lives with?

Both ParentsMotherFatherCaregiver

Parent/Caregiver 1

Last Name

Cell Number

Home Address:

City:

State:

Zip:

Parent/Caregiver 2

Last Name

Cell Number

Home Address

If different from above

City:

State:

Zip:

STUDENT INFORMATION

Name of Student 1

Nickname

What does your student preferred to be called?

Student 1 Birth Date

Hebrew Name

Does the child have any allergies?

YesNo

Does the child take any prescription medication(s)?

YesNo

If yes, please list

Does the child have any special physical or emotional needs?

Please explain

Has the child had any psychological or educational evaluation(s)?

YesNo

If Yes, please submit a copy of the report.

Do you need to register a second child?

YesNo

Name of Student 2

Nickname

What does your child prefer to be called?

Student 2 Birth Date

Hebrew Name

Does the child have any allergies?

YesNo

Does the child take any prescription medication(s)?

YesNo

If yes, please list

Does the child have any special physical or emotional needs?

Please explain

Has the child had any psychological or educational evaluation(s)?

YesNo

If Yes, please submit a copy of the report.

Do you need to register a third child?

YesNo

Name of Student 3

Preferred Name:

What does your child prefer to be called?

Student 3 Birth Date

Hebrew Name

Does the child have any allergies?

YesNo

Does the child take any prescription medication(s)?

YESNO

If yes, please list

Does the child have any special physical or emotional needs?

Please explain

Has the child had any psychological or educational evaluation(s)?

YesNo

If Yes, please submit a copy of the report.

EMERGENCY CONTACT & MEDICAL INFORMATION

Does your family have Health Insurance?

Name of Health Insurance Company:

Policy Number

* Name of emergency contact: (person other than parents/guardians):

* Emergency contact phone number:

* Name of emergency contact: (person other than parents/guardians):

* Emergency contact phone number:

* Do you give consent for emergency medical treatment of your child(ren)?

YesNo

* Preferred Hospital:

* Physician's Name:

* Physician's Phone Number:

* Dentist's Name:

* Dentist's Phone Number:

I give permission for ATJC to use photos of my child(ren) in future communications including print and social media.

YesNo

Please sign electronically to signify your student(s) and family's understanding and commitment to our Brit (Covenant)

Fri, September 25 2020 7 Tishrei 5781