Shalom Preschool Registration

SHALOM PRESCHOOL PROGRAM - REGISTRATION FORM 5784/2023-2024

Friday – 9:00 am to 1:00 pm
Date:

MonthDayYear
Date
Beth Tikvah member?

YesNo
Child's full name:

First NameLast Name
Age in September:
Birth Date:

MonthDayYear
Sex:

MF
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Name:

First NameLast Name
Occupation:
E-mail:
Parent/Guardian's Daytime Phone Number:

Area CodePhone Number
Parent/Guardian's Cell Phone Number:

Area CodePhone Number
Parent/Guardian's Name:

First NameLast Name
Occupation:
E-mail:
example@example.com
Parent/Guardian's Daytime Phone Number:

Area CodePhone Number
Parent/Guardian's Cell Phone Number:

Area CodePhone Number
Number of Adults at home :
Number of Children at home:
Children's General Health:
Special Needs, Serious Illness (past or present), Allergies:
Child's previous experience in a group:
Child's special likes:
Child's special dislikes or fears:
Does your child have any medical and/or emotional problems?
Has your child had previous experience away from home (Daycare, Nursery, etc.)?
Were there any special problems?
Special words used by your child for toileting:
Any further information which will help the teacher get to know your child (Please include any relevant birth history information):
How did you hear about our program?

RELEASE FORM

Shalom Preschool
Child's Name:
RELEASE OF PHONE NUMBERS AND ADDRESSES:

At the beginning of each Shalom Preschool program, the synagogue provides a list of all children enrolled in each class along with their parents' names, addresses and phone numbers to the families with children enrolled in our preschool program. This list is periodically updated and redistributed throughout the year. Your personal information will not be disclosed to anyone for business or commercial purposes.
I give my consent for release of my home address and phone number.

Yes
I do not permit the release of my home address and phone number.

No
PHOTOGRAPHS, NAMES AND MEDIA COVERAGE:

It is tradition in our programs to allow staff, parents and the media to photograph individual children or groups of children to commemorate various religious holidays or to promote other cultural or educational events taking place in our synagogue. Consent is required for the release of these pictures to be published along with your child's name and any comments your child may make that will be published. They may be published in our synagogue's newsletters or in our local newspapers and on rare occasions on television.
I give consent for the use of my child's name, photograph and comments for purposes consistent with the above.

Yes
I do not permit the use of my child's name, photograph and comments.

No
Signature Parent/Guardian

Clear
Date

MonthDayYear
Date

PARENTAL CONSENT FORM

Shalom Preschool
Dear Parent/Guardian

"Outings" are short walks outside of the building and playground, but within the property of the Beth Tikvah Synagogue. These walks are included in the Shalom Preschool Program in order to give the children enrolled an opportunity to explore and discover the outdoors. We request your support and consent with the understanding that all necessary precautions will be taken to ensure the safety of each child on these "outings".
I give my consent for my child/ren to be taken on "outings" within the property of the Beth Tikvah Synagogue.
Parent/Guardian's Signature

Clear
Date

MonthDayYear
Date
Release Form

I understand that I assume all risks and hazards incidental to the conduct of this activity, and hereby release, absolve, indemnify and hold harmless Beth Tikvah Congregation and Centre Association, directors, supervisors and employees from all claims or injuries arising therefrom
Parent/Guardian's Signature

Clear
Date

MonthDayYear
Date

AUTHORIZATION FOR PICKUP

Shalom Preschool
I
My name
authorize the following people only to pick up my child
Child's name
from his/her Beth Tikvah Program.
1.
2.
3.
4.
5.
6.
I understand that according to Licensing Regulations the teachers are not permitted to release my child to anyone not listed above without additional written permission provided by myself.
Parent/Guardian's Signature

Clear
Date

MonthDayYear
Date

EMERGENCY CONSENT FORM

Shalom Preschool
It is the policy of this Centre to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Our procedure is to take the child to the nearest emergency service.

Please sign below so that we can take appropriate action on behalf of your child. Return the signed card to the Centre immediately.
I hereby give consent for my child
Child's name
when ill to be taken to the nearest emergency centre by the staff of Beth Tikvah Congregation and Centre Assn. when I cannot be contacted. I consent to an ambulance being called to transport the child, if necessary.
Parent/Guardian's Signature

Clear
Date

MonthDayYear
Date
EMERGENCY INFORMATION

Shalom Preschool
Name:

First NameLast Name
Birth Date:

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Phone Number:

Area CodePhone Number
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Phone Number:

Area CodePhone Number
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:

Area CodePhone Number
Child's Physician:

First NameLast Name
Physician's Phone Number:

Area CodePhone Number
Date of most recent Tetanus shot:

MonthDayYear
Date
Care card number:
Medications:
Medical Conditions/Allergies:
Child's Dentist:

First NameLast Name
Phone Number:

Area CodePhone Number
Should be Empty:

SHALOM PRESCHOOL PROGRAM - REGISTRATION FORM 5784/2023-2024