Youth Group Registration 2020-2021 - Form - Congregation Shaarei Kodesh

Please complete the below registration form.

* Student's First Name

* Nickname

* Student's Last Name

* Student's Hebrew Name

Student's Gender

Student's Date of Birth

Are your child's vaccinations up to date?

YesNoPlease email copy of most recent vaccination form to office@shaareikodesh.org

Please fill in medical insurance information.

Health Insurance Company

Insurance Company Phone#

Health Insurance Policy #

* Student's Cell Phone Number (If Available)

* I, student, give permission to receive messages and alerts via text to this designated cell phone.

YesNo

* Local Address

City

State

Zip

Is your child new to youth group?

YesNo

Grade as of 9/1/2020

School Attending

Enter your e-mail address here if it does not automatically populate.

FAMILY CONTACT INFORMATION

* Guardian #1 First Name

Guardian #1 Last Name

* Address if Different from Child

City

State

Zip

* Guardian #1 Email

* Guardian #1 Cell Phone

Guardian #2 Email

Guardian #2 Cell Phone

* Guardian #2 First Name

Guardian #2 Last Name

* Address (Guardian #2) if Different from Child

City

State

Zip

* I (Guardian #1) give permission to receive messages and alerts via text to this designated cell phone.

YesNo

I (Guardian #2) give permission to receive messages and alerts via text to this designated cell phone.

YesNo

PROGRAM OPTIONS

Please select appropriate program, tuition and fees.

USY (9th-12th Grade) Members - $36USY (9th-12th Grade) Non-Members - $54Kadima (6th-8th Grade) Members $36Kadima (6th-8th Grade) Non-Members $54Chalutzim (3rd-5th Grade) Members $18Chalutzim (3rd-5th Grade) Non-Members $36

Please share with us any other important information that will help us provide a safe and caring learning environment for your child.

Does your child have any ALLERGIES? (PLEASE LIST ALL ALLERGIES)

Permission to photograph/video your child and use (without names) for promotional purposes?

YesNo

CONFIDENTIAL: Are there any health conditions (physical or mental) we should know about that may affect your child's attendance or participation at events? If yes, please explain.

EMERGENCY CONTACT AND PICK-UP INFORMATION
In addition to guardians, please list two (2) emergency contacts/authorized individuals for pick up:

Name:

Phone Number:

Relationship:

Can Pick Up? Y/N

Name:

Phone Number:

Relationship:

Can Pick Up? Y/N

Dues Total

APPLICATION FOR ENROLLMENT AND LIABILITY RELEASE

I hereby submit registration for my child, as listed above, for the Congregation Shaarei Kodesh (CSK) Religious School Program during the 2020-2021 school year. I understand that session and class placement of my child is left to the discretion of the Director. In the event of an emergency, I give permission for my child to be brought to the nearest medical facility and authorize the representative of Congregation Shaarei Kodesh to select a physician, nurse, paramedic or emergency medical technician licensed by the State of Florida, and/or authorize medical treatment, including hospitalization, anesthesia, injection, surgery or other measures which he/she feels are in the best interest of my child. This form also serves as a release form for any trip on which my child participates during the school year. I also, hereby release and agree to defend, indemnify and hold Congregation Shaarei Kodesh (and its officers, directors, agents, volunteers and employees) harmless from any and all damages, injuries, claims and causes of action arising (directly or indirectly) out of my or my child’s participation on any school-sponsored activity or trip. My child has my permission to participate in all activities of the Education Program for which he/she is registered.

By signing this application, the undersigned agrees to pay the total amount of tuition and fees for the 2020-2021 school year. In the event of payment default, CSK reserves the right to cancel the student’s enrollment and the undersigned agrees to pay the expenses of enforcement and collection, including attorney’s fees and costs.

CONFIRMING APPLICATION FOR ENROLLMENT AND PERMISSIONS

YESNo