Registration
Please email or print and mail this form to:
CJL, 194 Jackson St, Northampton, MA 01060 (Checks payable to CJL) OR Pay Here
STUDENT NAME: ________________________________________________
School: __________________________________________________________
Grade in September: ______
Hebrew name: ____________________________________________________
Parent name: ______________________________________________________
Address: __________________________________________________________
Phone numbers:
Cell___________________Home___________________Work____________________
E-mail: _______________________________
Parent name: ______________________________________________________
Address: __________________________________________________________
Phone numbers: Cell___________________Home___________________Work____________________
E-mail: _______________________________
I'm interested in learning about volunteer opportunities: _____ yes _____ no
EMERGENCY CONTACT Information:
NAME: _____________________________________________
Phone numbers in order of accessibility (i.e. cell, work or home) 1.____________________________
2. ____________________________
Relationship to student________________________________
Family Physician _____________________________________ Phone_______________________________
** Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.
Medical Insurance Provider: _________________________________
Group or ID #: ____________________________________________
I hereby give consent to the CJL to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.), or dentist (D.D.S.) for my child(ren). This care may be given under whatever conditions are necessary to preserve life, limb, or well being of the child(ren) named above.
I understand that I will be contacted immediately, as will my child's physician.
Parent name (print): _________________________________________
Parent signature: ____________________________________________ Date: ____________________
Please describe any learning challenges or special needs.
CJL, 194 Jackson St, Northampton, MA 01060 (Checks payable to CJL) OR Pay Here
STUDENT NAME: ________________________________________________
School: __________________________________________________________
Grade in September: ______
Hebrew name: ____________________________________________________
Parent name: ______________________________________________________
Address: __________________________________________________________
Phone numbers:
Cell___________________Home___________________Work____________________
E-mail: _______________________________
Parent name: ______________________________________________________
Address: __________________________________________________________
Phone numbers: Cell___________________Home___________________Work____________________
E-mail: _______________________________
I'm interested in learning about volunteer opportunities: _____ yes _____ no
EMERGENCY CONTACT Information:
NAME: _____________________________________________
Phone numbers in order of accessibility (i.e. cell, work or home) 1.____________________________
2. ____________________________
Relationship to student________________________________
Family Physician _____________________________________ Phone_______________________________
** Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.
Medical Insurance Provider: _________________________________
Group or ID #: ____________________________________________
I hereby give consent to the CJL to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.), or dentist (D.D.S.) for my child(ren). This care may be given under whatever conditions are necessary to preserve life, limb, or well being of the child(ren) named above.
I understand that I will be contacted immediately, as will my child's physician.
Parent name (print): _________________________________________
Parent signature: ____________________________________________ Date: ____________________
Please describe any learning challenges or special needs.
