CKids Registration

Full Name*

First Name Last Name

E-mail*

Phone Number*

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Number of Children Registering:*

Child 1: Full Name*

First Name Last Name

Child 1: Birth Date*

Month Day Year

Child 1: Gender*

MaleFemale

Child 1: Help us determine the Hebrew Birthday:*

Born during the dayBorn in the eveningBorn at dusk/ sunset

Child 1 Attending:*

Child 2: Full Name

First Name Last Name

Child 2: Birth Date

Month Day Year

Child 2: Gender

MaleFemale

Child 2: Help us determine the Hebrew Birthday:

Born during the dayBorn in the eveningBorn at dusk/ sunset

Child 2 Attending:*

Child 3: Full Name

First Name Last Name

Child 3: Birth Date

Month Day Year

Child 3: Gender

MaleFemale

Child 3: Help us determine the Hebrew Birthday:

Born during the dayBorn in the eveningBorn at dusk/ sunset

Child 3 Attending:*

Child’s Physician:*

Physician’s Phone Number:*

Area Code Phone Number

Physician’s Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insurance Company Covering the Child(ren)*

Policy Number Child 1:*

Policy Number Child 2:

Policy Number Child 3:

Expiration Date:*

Please list below any psychological or medical conditions,medications currently being taken ,dietary requirements,allergies (include allergies to medications) etc pertaining to your child.*

1. Full Name:*

First Name Last Name

1. Relationship:*

1. Cell Phone*

Area Code Phone Number

2. Full Name*

First Name Last Name

2. Relationship:*

2. Cell Phone*

Area Code Phone Number

(Electronic) Signature of Parent.:*

Date:*

Month Day Year

I hereby give permission,in the event of an emergency, for the Director or the Teacher at North Shore CKIDS to take whatever steps maybe necessary for the medical care of my child(ren). I understand that in order for the North Shore CKIDS to assume responsibility for my child,I or the persons whom I have designated to pick up my child in an emergency.I understand that unless there is a need for immediate action, the order of the steps taken will follow,but will not be limited to, the outline below: 1.The parent/ guardian will be called. 2.Note: If the parent/guardian is unavailable,the emergency contact person designated by the parent/guardian will be called. 3.Child’s physician will be called. 4.If these efforts are unsuccessful the following steps will be taken(order may vary depending on the situation): I. Another physician will be called. II.The child will be taken to the nearest emergency room accompanied by a staff member. III An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member. I give consent to any emergency facility and physician to administer any necessary medical treatment to my child as the situation may warrant it.*

Parent/Guardian’s Signature Date

Transport/Emergency Care as listed above*

I give permissionI don't give permission

I give permission to North Suburban Lubavitch Chabad - Central Avenue Synagogue, and those authorized by Chabad, to take photographs and to make recordings of my children and my family, and to use them in original or modified form in all media now or hereafter known, with or without my name or information about me, for the promotion, public education, and/or fundraising activities of North Suburban Lubavitch Chabad - Central Avenue Synagogue.*

I give permissionI don't give permissionI allow with the exception of Facebook.

Initial Here:*

Authorized to pick up:*

Emergency ContactParentsOther

Other Pick up:

Pick up's Number:

Area Code Phone Number

Total

$0.00

Payment*

Credit Card Check

Postal / Zip Code

Country

I would like to receive news and updates by email

Child 1 information:

Child 2 Information:

Child 3 Information:

Medical Information

Emergency Contacts:

Permission forms

Payment Information