Beth Jacob Hebrew School 2023-2024 Registration Form (9 -11 years old)
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Age
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# 1 Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
# 2 Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who would you like to be the main contact
First Parent/ Guardian
Second Parent/ Guardian
Both
Other
Emergency Contact Name (In case we can't reach you)
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Any Allergies or Medical Conditions?
Yes
No
Please give details
Please upload a profile picture of the child
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I, undersigned, agree with the following statements:
I am the parent/guardian of the child indicated above.
If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.
I am giving my permission to take my child's pictures for classroom projects and post them on the class app.
I am giving my permission to take my child's pictures for classroom projects and post them on the Beth Jacob website
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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