Kesher Registration

* Student's Last Name

* Student's First Name

Student's Hebrew Name

* Student's date of birth

* Student's grade level in Sept. 2024

Name of school student will attend for 2024-2025

* Student's primary address

* Home phone number

Please list any allergies your child has. What is the typical reaction and treatment?

Any special learning needs/IEP/Social strategies/etc.?

* Student email

* Student cell phone #

* Register my child for the following class

* Parent/Guardian 1 Full Name

* Parent/Guardian 1 email

* Parent/Guardian 1 Cell phone #

* Parent/Guardian 2 Full Name

* Parent/Guardian 2 email

* Parent/Guardian 2 Cell phone #

* Emergency contact name

* Emergency Contact's relationship to student

* Emergency Contact phone number

* Health Insurance company name

* Name of insured

* Policy number

* Group number

* Insurance company address and phone number

* Photographs and video images of students in the EBJC education and youth programs are routinely taken for the purpose of celebrating student achievement and sharing educational programs with the community. Photographs may be submitted to area newspapers. Video footage may be submitted to area news outlets that cover special events that occur in the area or posted to websites. Please check 1 box below.

I GRANT permissionI DO NOT GRANT permission

* List ALL medications taken routinely by student, including prescription, over-the-counter, and non-prescription. If none, write "none."

* Is student fully vaccinated (COVID included)?

* Please explain in detail any answers that are checked

* PARENT'S AUTHORIZATION AND PERMISSION TO PROVIDE EMERGENCY CARE: My typed name below indicates my agreement with the following: To the best of my knowledge, the medical history is correct and complete. I know of no reason to restrict the participant's activity and hereby give my permission for participation in all activities except as specifically noted herein. In the event that I cannot be reached in an emergency, I hereby give permission to the medical personnel selected by the East Brunswick Jewish Center to order x-rays, routine tests, treatment, and transportation for my child. I also hereby give permission to the physician selected by EBJC to secure and administer treatment, including hospitalization, for the persons named above.

* Synagogue the family belongs to (if unaffiliated, write "None").

Kesher & Youth Group Registration