Registration Forms
2022-2023 Applications
CHILD'S NAME
*
First Name
Last Name
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PLEASE CHOOSE A SARFAN EARLY CHILDHOOD PROGRAM
*
Infant/Toddler
Preschool
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INFANT / TODDLER 2022-2023
Ages 6 weeks to 12 months
CHILD'S DATE OF BIRTH
*
-
Month
-
Day
Year
Date
CHILD'S GENDER
*
Please Select
Male
Female
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER TO LIST ON ROSTER
*
EMAIL TO LIST ON ROSTER
*
example@example.com
PARENT 1 NAME
*
PARENT 1 ADDRESS (if different from above)
PARENT 1 CELL #
*
PARENT 1 WORK # / OTHER #
PARENT 1 WORKPLACE NAME & ADDRESS
PARENT 2 NAME
PARENT 2 ADDRESS (if different from above)
PARENT 2 CELL #
PARENT 2 WORK # / OTHER #
PARENT 2 WORKPLACE NAME & ADDRESS
PLEASE SELECT INFANT/TODDLER PROGRAM
Please Select
INFANTS 6 wks-12 mos: FULL TIME 8am-5pm - $1325/month
MAZEL TOTS 12-24 mos (By Sept 30): PART TIME 9am-12pm - $625/month
MAZEL TOTS 12-24 mos (By Sept 30): FULL TIME 8am-5pm - $1100/month
The Sarfan Center is open year-round to meet the needs of our families. Please let us know your needs by selecting the enrollment option below:
*
10 Month Enrollment (September - Mid June)
12 Month Enrollment
Medical Information
Please list any allergies relevant to school
Please list any medications your child takes on a regular basis
Please list any medical diagnoses, any potential problems or unusual aspects of your child's life that might affect his/her performance at school that we should be aware of
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Add Child #2?
*
Yes
No
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PRESCHOOL 2022-2023
Ages 2 to Kindergarten
CHILD'S DATE OF BIRTH
*
-
Month
-
Day
Year
Date
CHILD'S GENDER
*
Please Select
Male
Female
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER TO LIST ON ROSTER
*
EMAIL TO LIST ON ROSTER
*
example@example.com
PARENT 1 NAME
*
PARENT 1 ADDRESS (if different from above)
PARENT 1 CELL #
*
PARENT 1 WORK # / OTHER #
PARENT 1 WORKPLACE NAME & ADDRESS
PARENT 2 NAME
PARENT 2 ADDRESS (if different from above)
PARENT 2 CELL #
PARENT 2 WORK # / OTHER #
PARENT 2 WORKPLACE NAME & ADDRESS
PLEASE SELECT PRESCHOOL PROGRAM
Please Select
PRESCHOOL 2 YEAR OLDS: PART TIME 9am-12pm - $575/month
PRESCHOOL 2 YEAR OLDS: FULL TIME 8am-5pm - $1050/month
PRESCHOOL 3 YEAR OLDS: PART TIME 9am-12pm - $550/month
PRESCHOOL 3 YEAR OLDS: FULL TIME 8am-5pm - $1025/month
PRE-K & KINDERGARTEN: FULL DAY 9am-3pm - $725/month
PRE-K & KINDERGARTEN: EXTENDED DAY 8am-5pm - $925/month
The Sarfan Center is open year-round to meet the needs of our families. Please let us know your needs by selecting the enrollment option below:
*
10 Month Enrollment (September - Mid June)
12 Month Enrollment
Medical Information
Please list any allergies relevant to school
Please list any medications your child takes on a regular basis
Please list any medical diagnoses, any potential problems or unusual aspects of your child's life that might affect his/her performance at school that we should be aware of
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Add Child #2?
*
Yes
No
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Child #2
CHILD'S NAME
*
CHILD'S DATE OF BIRTH
*
-
Month
-
Day
Year
Date
CHILD'S GENDER
*
Please Select
Male
Female
PLEASE SELECT SCHOOL PROGRAM (10% multiple child discount)
*
Please Select
INFANTS 6 wks-12 mos: FULL TIME 8am-5pm - $1192.50/month
MAZEL TOTS 12-24 mos (By Sept 30): PART TIME 9am-12pm - $562.50/month
MAZEL TOTS 12-24 mos (By Sept 30): FULL TIME 8am-5pm - $990/month
PRESCHOOL 2 YEAR OLDS: PART TIME 9am-12pm - $517.50/month
PRESCHOOL 2 YEAR OLDS: FULL TIME 8am-5pm - $945/month
PRESCHOOL 3 YEAR OLDS: PART TIME 9am-12pm - $495/month
PRESCHOOL 3 YEAR OLDS: FULL TIME 8am-5pm - $922.50/month
PRE-K & KINDERGARTEN: FULL DAY 9am-3pm - $652.50/month
PRE-K & KINDERGARTEN: EXTENDED DAY 8am-5pm - $832.50/month
PLEASE SELECT ENROLLMENT OPTION
*
10 Month Enrollment (September - Mid June)
12 Month Enrollment
Medical Information
Please list any allergies relevant to school
Please list any medications your child takes on a regular basis
Please list any medical diagnoses, any potential problems or unusual aspects of your child's life that might affect his/her performance at school that we should be aware of
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Add Child #3?
*
Yes
No
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Child #3
CHILD'S NAME
*
CHILD'S DATE OF BIRTH
*
-
Month
-
Day
Year
Date
CHILD'S GENDER
*
Please Select
Male
Female
PLEASE SELECT SCHOOL PROGRAM (10% multiple child discount)
*
Please Select
INFANTS 6 wks-12 mos: FULL TIME 8am-5pm - $1192.50/month
MAZEL TOTS 12-24 mos (By Sept 30): PART TIME 9am-12pm - $562.50/month
MAZEL TOTS 12-24 mos (By Sept 30): FULL TIME 8am-5pm - $990/month
PRESCHOOL 2 YEAR OLDS: PART TIME 9am-12pm - $517.50/month
PRESCHOOL 2 YEAR OLDS: FULL TIME 8am-5pm - $945/month
PRESCHOOL 3 YEAR OLDS: PART TIME 9am-12pm - $495/month
PRESCHOOL 3 YEAR OLDS: FULL TIME 8am-5pm - $922.50/month
PRE-K & KINDERGARTEN: FULL DAY 9am-3pm - $652.50/month
PRE-K & KINDERGARTEN: EXTENDED DAY 8am-5pm - $832.50/month
PLEASE SELECT ENROLLMENT OPTION
*
10 Month Enrollment (September - Mid June)
12 Month Enrollment
Medical Information
Please list any allergies relevant to school
Please list any medications your child takes on a regular basis
Please list any medical diagnoses, any potential problems or unusual aspects of your child's life that might affect his/her performance at school that we should be aware of
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Add Child #4?
*
Yes
No
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Child #4
CHILD'S NAME
*
CHILD'S DATE OF BIRTH
*
-
Month
-
Day
Year
Date
CHILD'S GENDER
*
Please Select
Male
Female
PLEASE SELECT SCHOOL PROGRAM (10% multiple child discount)
*
Please Select
INFANTS 6 wks-12 mos: FULL TIME 8am-5pm - $1192.50/month
MAZEL TOTS 12-24 mos (By Sept 30): PART TIME 9am-12pm - $562.50/month
MAZEL TOTS 12-24 mos (By Sept 30): FULL TIME 8am-5pm - $990/month
PRESCHOOL 2 YEAR OLDS: PART TIME 9am-12pm - $517.50/month
PRESCHOOL 2 YEAR OLDS: FULL TIME 8am-5pm - $945/month
PRESCHOOL 3 YEAR OLDS: PART TIME 9am-12pm - $495/month
PRESCHOOL 3 YEAR OLDS: FULL TIME 8am-5pm - $922.50/month
PRE-K & KINDERGARTEN: FULL DAY 9am-3pm - $652.50/month
PRE-K & KINDERGARTEN: EXTENDED DAY 8am-5pm - $832.50/month
PLEASE SELECT ENROLLMENT OPTION
*
10 Month Enrollment (September - Mid June)
12 Month Enrollment
Medical Information
Please list any allergies relevant to school
Please list any medications your child takes on a regular basis
Please list any medical diagnoses, any potential problems or unusual aspects of your child's life that might affect his/her performance at school that we should be aware of
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Emergency Contact
In the event we cannot reach you
Emergency Contact 1
*
Emergency Contact 1 Phone Number
*
Relationship to Child
*
Emergency Contact 2
*
Emergency Contact 2 Phone Number
*
Relationship to Child
*
Children will only be released to parents / guardians, emergency contacts or names listed below (after verification of ID).
Children may be released to:
Phone Number
Relationship to Child
Children may be released to:
Phone Number
Relationship to Child
Children may be released to:
Phone Number
Relationship to Child
Please list anyone NOT authorized to pick up your child. If it is a parent who has a legal right, any court order document MUST be on file.
Children MAY NOT be released to:
Relationship to Child (if any)
Household
PLEASE SELECT YOUR FAMILY STATUS (If Separated or Divorced is selected, a custody agreement is required to keep on file.)
*
Single
Married
Separated*
Divorced*
Child Lives with:
*
Other Adults living in the home:
*
Number of children in the family:
*
Please list sibling names, birth dates, gender, age, grade & name of school (if applicable)
Synagogue Affiliation
Please select
*
Adath Jeshurun Synagogue
Congregation Emet v'Or
Rodef Sholom Temple
Temple Beth El
Temple Sinai
Unaffiliated
I identify as Jewish
Other
Physician & Hospital Information
Family Physician Name
*
Practice
*
Physician address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Phone Number
*
Dentist Name
*
Dental Practice
*
Dentist Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist Phone Number
*
Child's Insurance
*
Subscriber Name
*
First Name
Last Name
Policy #
*
Phone Number
*
Are you able to occasionally be a classroom substitue?
Yes
No
If you are able to be a classroom substitute, please indicate your availability
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Sarfan Early Childhood Center Terms & Agreements
All prior financial obligations to the United Jewish Community must be fulfilled before registration is accepted.
Application Fee
*
Tuition
*
Additional Documents
*
Delinquent Account
*
Transportation: My child(ren) has/have permission to be transported by bus or van provided by the Sarfan Center. Children will be supervised and accompanied by preschool staff at all times.
*
Yes, the UJC has my permission to transport my child(ren).
No, the UJC does not have my permission to transport my child(ren).
Photograph & Video Permission: Children at the Sarfan Early Childhood Center may occasionally have their photo, name, image or likeness used for UJC publications (including our website, newsletter, social media outlets) and promotions (including articles, radio and television entities). The UJC has my permission to do this.
*
Yes, the UJC has my permission to use photos and videos of my child(ren).
No, the UJC does not have my permission to use photos and videos of my child(ren).
I hereby request that the above named child(ren) be enrolled in the Sarfan Early Childhood Center for the 2022-2023 school year. I understand I have an obligation for the full tuition for the program(s) I have selected for my child(ren), regardless of my child(ren)'s attendance. I understand that in the event of a vacation or illness or any other prolonged absence from the school, the tuition must be paid in full. No refunds are provided. I understand that submitting this registration form along with the non-refundable deposit will register my child for the 2021-2022 school year.
*
I understand and accept full financial responsibility for all fees and payments related to participating in the Sarfan Early Childhood Center programs.
*
I understand I will receive a copy of the Sarfan Early Childhood Center handbook the first week of school and will abide by the information and rules.
*
Enrollment in the Sarfan Early Childhood Center includes a Family Program Passport Membership to the United Jewish Community of the Virginia Peninsula (which includes summer use of Glendale Pool).
*
I have read the statement and agree to the above mentioned terms. I agree to adhere to the rules and regulations of the Sarfan Early Childhood Center.
*
Parent / Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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Thank you for submitting your Sarfan Center 2022-2023 Registration Form!
If you have any questions, please call the UJC Main Office at 757-930-1422.
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