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7th Grade Teen Torah Registration 19/20
Please verify reCaptcha before submitting the form.
7th 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 Parents
Mother
Father
Caregiver
Parent/Caregiver 1
Last Name
Email
Cell Number
Home Address:
City:
State:
Zip:
Parent/Caregiver 2
Last Name
Email
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?
Yes
No
Does the child take any prescription medication(s)?
Yes
No
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)?
Yes
No
If Yes, please submit a copy of the report.
Do you need to register a second child?
Yes
No
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?
Yes
No
Does the child take any prescription medication(s)?
Yes
No
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)?
Yes
No
If Yes, please submit a copy of the report.
Do you need to register a third child?
Yes
No
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?
Yes
No
Does the child take any prescription medication(s)?
YES
NO
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)?
Yes
No
If Yes, please submit a copy of the report.
EMERGENCY CONTACT & MEDICAL INFORMATION
Does your family have Health Insurance?
YES
NO
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)?
Yes
No
*
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.
Yes
No
Please sign electronically to signify your student(s) and family's understanding and commitment to our Brit (Covenant)
Thu, April 18 2024 10 Nisan 5784