Congregation Kehillah Youth Education Program

Congregation Kehillah Youth Education Program
YEP! Registration Form for 2022/23
A Registration Form for each child must be completed every year, before a child may attend classes.
CHILD'S LAST NAME
CHILD'S FIRST NAME
CHILD'S MIDDLE NAME
HEBREW NAME
Please select one:

Male Female
Birth Date

Month Day Year
Date
Current Age
Child's Cell (if applicable)
Child's Email (if applicable)
example@example.com
Grade entering in fall 2022
Name of School
School District
If new to Congregation Kehillah and YEP! please list prior religious school education and grade level
Parent #1 Full Name
Parent #1 Cell
Parent #1 Email
example@example.com
Home Phone
Parent #2 Full Name
Parent #2 Cell
Parent #2 Email
example@example.com
PHOTOGRAPHIC RELEASE

During the school year we take pictures that may include your child. These pictures may be used in our newsletters, onour website and for publicity. Check the box to the left if you APPROVE the use of these photos and please sign below.
Parent or Guardian Signature

Clear
$125 Supply/Activity fee per child. This fee will help defray the cost of work books, art supplies, snacks and other purchased items during the school year. Please include payment with this form. Thank you. B'nai Mitzvah fees are not included. Donations to Congregation Kehillah are always appreciated.
Emergency Contact Information
Physician's Name
Physician's Phone Number
Address

Street Address

Street Address Line 2

City
Emergency Contact #1 Name (other than parent or guardian)
Emergency Contact #1 relationship to child
Emergency Contact #1 Phone Number
Please enter a valid phone number.
Emergency Contact #2 Name (other than parent or guardian)
Emergency Contact #2 relationship to child
Emergency Contact #2 Phone Number
Please enter a valid phone number.
In the event that I/we cannot be contacted, I/we hereby give authority to any hospital or doctor to render immediate aid as required at the time for my child's health and safety. I/we understand I/we am/are responsible for this expense.
Parent or Guardian Signature

Clear
Date

Month Day Year
Date
ADDITIONAL HISTORY / IMPORTANT INFORMATION

Yes No
ADDITIONAL HISTORY / IMPORTANT INFORMATION
Is there more than one religion observed your home?

Yes No
If yes, please explain:
Does your child have any allergies?

Yes No
If yes, please list all allergies
Does your child have asthma or a respiratory condition?

Yes No
If yes, please explain:
Does your child take any medications on a daily basis?

Yes No
If yes, please list what kind:
So that we might provide the best learning environment for your child, please share any of your child's emotional, behavioral, physical or learning needs of which we should be aware
Is your child in any special class for any reason?

Yes No
If yes, please explain:
In the case of divorce, to which parent should YEP! information be sent?

Both Mother Father
Is there anything else that we should know about your child?
Should be Empty:

Congregation Kehillah Youth Education Program

YEP! Registration Form for 2022/23

Emergency Contact Information

ADDITIONAL HISTORY / IMPORTANT INFORMATION