Circles for Jewish Living
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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.

 



 



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