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Address

Email
Father's Name
Father's Cell

Area Code Phone Number
Mother's Name
Mother's Cell

Area Code Phone Number
Emergency Contact 1

First Name Last Name
Phone Number

Area Code Phone Number
Emergency Contact 2

First Name Last Name
Phone Number

Area Code Phone Number
Doctor's Name

First Name Last Name
Phone Number

Area Code Phone Number
CONFIDENTIAL: If your child has any allergies or other medical condition we should be aware of please describe them and indicate special precautions or care needed.
Parental Authorization

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad of the Beaches to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of the Beaches personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in all activities and that these pictures may be used for marketing purposes.
Cost for the year $72

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