Family, Health, and Emergency Information Form

New to the Jewish Enrichment Center? Welcome! Please fill out this form so we can help keep your child/ren safe.

Family, Health, and Emergency Form 2023-2024

Parent/Guardian 1 Full Name *

Parent/Guardian 1 Preferred Pronouns

Parent/Guardian 1 Profession

Parent/Guardian 1 Email *

Parent/Guardian 1 Phone Number *

Parent/ Guardian 1 Alternate Phone Number

Parent/Guardian 2 Full Name

Parent/Guardian 2 Preferred Pronouns

Parent/Guardian 2 Profession

Parent/Guardian 2 E-mail

Parent/Guardian 2 Phone Number

Parent/Guardian 2 Alternate Phone Number

Which parent/guardian phone should we try first? *

Child Full Name *

Child Preferred Pronouns

Child's Grade for Fall 2023 *

Child’s Birthdate *

Child's Time of Birth *

Child lives with *

What school does your child attend? *

Does your child have an IEP or any classroom strategies that support their learning?

Please list your child’s medication(s) and when they are administered. If not applicable, write “none." *

Please list your child’s allergies (animal, food, latex), and their symptoms (breathing problems, runny nose, watery eyes). If not applicable, write “none." *

Does your child have an EpiPen? *

Yes

Child Home Address (please include zip code) *

Should mail also be sent to another address (e.g., a second parent)? If so, please note the address below.

Does your family participate regularly in Jewish programming? If so, please list below or write "none." * *

Do you observe any other religion in your home? *

We value multiple approaches to Judaism. Some families choose to belong to a synagogue. If synagogue affiliation is part of your family's Jewish life, please indicate which one(s). *

Photo Release: I grant permission for my child’s photo without their name, to be included in Jewish Enrichment Center printed and online materials. *

Yes

Emergency Contact Name (other than parent/guardian) *

Emergency Contact Phone Number

Emergency Contact relationship to child *

Is the Emergency Contact authorized to pick up your child? *

Yes

Who else is authorized to pick up your child? Please list two names, phone, and relationship to child/ren. *

Thank you! Is there anything else you’d like us to know about your child/ren? We're looking forward to getting to know your family!

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Family, Health, and Emergency Information Form

In this section

Phone: 708-529-5237

Family, Health, and Emergency Information Form

In this section

Phone: 708-529-5237

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