Jewish Family Experience Registration Form
A Sunday Jewish enrichment program, powered by the Jacksonville Community Kollel
Child's Information
Name
*
First Name
Last Name
Hebrew name (if applicable)
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current school
*
Previous Jewish education (if applicable)
Grade for 2022-2023 School Year
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Parent Information
Parent 1:
*
Mother
Father
Other
Parent 1: Name
*
First Name
Last Name
Parent 1: Hebrew Name (if applicable)
Parent 2:
*
N/A
Mother
Father
Other
Parent 2: Name
*
First Name
Last Name
Parent 2: Hebrew Name (if applicable)
Is the mother Jewish?
*
Yes
No
Mother is Jewish by:
*
Birth
Conversion
Self-Identity
Other
What's the best way for you to receive program updates?
Email
WhatsApp
Handouts
Other
Are you interested in volunteering?
*
Yes
No
Back
Next
Authorizations and Waivers
Authorized Pickup Name
First Name
Last Name
Authorized Pickup Phone Number
Please enter a valid phone number.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
Emergency Contact Phone Number
*
Please enter a valid phone number.
Allergies or Health issues we need to be aware of
*
If this is not applicable, write "None"
Is there anything else you'd like to share about you or your child?
Media Consent I give permission to the Jacksonville Community Kollel, and those authorized by the Jacksonville Community Kollel, to take photographs and to make recordings of my children and my family, and to use them in original or modified form in all media now or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities of the Jacksonville Community Kollel. Activities Consent My child has permission to engage in all programs and activities. Additionally, permission is hereby granted to the Jacksonville Community Kollel to take my child on trips outside of school as part of the regular school program. Medical Consent In the event that I cannot be contacted in an emergency or situation warranting medical attention, I hereby grant permission to The Jacksonville Community Kollel to bring my child/ren to the emergency room and/or give permission to the medical personnel selected by the program director to provide routine healthcare. Dismissal of Student The Jacksonville Community Kollel reserves the right to dismiss any student whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interest of the school, the student or their fellow students. In these instances, no refunds will be issued.
*
Agree
Disagree
Signature
*
Clear
Acceptance of Covid-19 Waiver
*
Clear
Submit
Should be Empty: