Youth Group Form 2022-2023 - Ramat Shalom Synagogue

11301 W. Broward Boulevard, Plantation, FL 33325 954-472-3600/ Fax 954-472-3622 ramatshalom@ramatshalom.org

Please indicate which program you are selecting. Please submit one form for each child!

Atid (Kindergarten-2nd Grade)
Machar (3rd Grade-5th Grade)

Child's Name: *

Hebrew Name: *

Phone: *

Email: *

School: *

Grade in School 2022-2023: *

Torah School Grade: *

Date of Birth: *

Age on 8/1/22: *

Identified Gender: *

Parent 1 Name: *

Parent 2 Name:

Parent 1 Phone: *

Parent 2 Phone:

Parent 1 Work Phone: *

Parent 2 Work Phone:

Parent 1 Email: *

Parent 2 Email:

Child lives with:

Parent 1
Parent 2
Both
Other

Relationship:

Emergency Information: In case of minor illness or injury of my child at school, I give the school staff permission to give basic first aid to my child. In case of a major injury or illness, I understand that staff will make every effort to contact me. If they are unable to do so, I give permission for my child’s physician and/or an ambulance to be contacted and for a physician to hospitalize and/or secure proper treatment for my child.

In case of an emergency call:

Emergency Contact 1 Name: *

Emergency Contact 2 Name:

Emergency Contact 1 Phone: *

Emergency Contact 2 Phone:

Emergency Contact 1 Reltionship: *

Emergency Contact 2 Reltionship:

My child may be picked up from Torah School by the following people:

Pickup List Name 1:

Pickup List Name 2:

Pickup List Phone 1:

Pickup List Phone 2:

Pickup List Relationship 1:

Pickup List Relationship 2:

List any allergies, medical conditions and/or daily medication: (Please notify the Torah School office of any changes)

Allergies:

Medical Conditions:

Medication:

Please provide any information about your child that may affect the classroom learning:

For example, specific learning issues, special needs, or educational accommodations.

Insurance Company:

Policy Number:

1. Electronic Items: Ramat Shalom is not responsible for any phones or games brought to school. We therefore suggest that you do not bring these items.

2. Publicity Release: I authorize pictures and/or videos of my child to be used for publicity and marketing purposes on the Ramat Shalom website, newspapers, magazines, social media, or marketing materials.

Electronic Signature: *

Date: *

In case of an emergency call:

My child may be picked up from Torah School by the following people:

List any allergies, medical conditions and/or daily medication: (Please notify the Torah School office of any changes)

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