Printed fromchabadwaterways.org

ב"ה

Shabbat Girls Club - Parents Registration Form

Parents Registration Form
For Girls Ages 9–11

Thank you for registering your daughter for Shabbat Girls Club! Please complete the information below so we can provide a safe, welcoming and meaningful experience for every girl.
PARTICIPANT INFORMATION
Girl's Full Name:*
First Name Last Name
Hebrew Name:*
First Name Last Name
Name She Likes to Be Called: *
Date of Birth*

Month Day Year
Born before or after nightfall:

During the day/before NightfallEvening- After Nightfall
Age:*
School*
Grade:*
PARENT / GUARDIAN INFORMATION
Parent/Guardian #1:*
First Name Last Name
Relationship to Child:*
Phone Number*
E-mail*
Parent/Guardian #2:
Relationship to Child:
Phone Number
E-mail
Home Address:*
EMERGENCY CONTACT

Please provide someone local other than a parent/guardian.
Name:*
Relationship to child:*
Phone:*
HEALTH & SAFETY
Does your daughter have any allergies, dietary restrictions or food sensitivities?*

NoYes
If yes, please explain:*
Does your daughter have any medical, behavioral, learning, sensory or other needs that would be helpful for our leaders to know about?*

NoYes
If yes, please explain:*
Is there anything we can do to help your daughter feel comfortable, included and successful in the group?
DISMISSAL / PICKUP
My daughter may leave at the end of the program:*

Only with a parent/guardianWith any of the authorized adults listed belowOn her own, with my permission
Additional adults authorized to pick up my daughter:
Name:*
Relationship:*
Name:
Relationship:
Is there anyone who is NOT authorized to pick up your daughter?*

NoYes — please provide details directly to the program director.
PHOTO & VIDEO PERMISSION
Photographs may occasionally be taken at the programs and events (excluding Shabbat) and may be used for Chabad Waterways communications, social media, and promotional purposes.*

YES, I give permission for my daughter to appear in photographs used by Chabad Waterways.NO, I do not give permission for my daughter to appear in photographs used by Chabad Waterways.
HELP US GET TO KNOW YOUR DAUGHTER
What do you hope your daughter will gain from Shabbat Girls Club?*
Is there anything about your daughter's personality, interests or friendships that would be helpful for our leaders to know?*
PARENT ACKNOWLEDGMENT
I confirm that the information provided above is accurate and that I will notify Shabbat Girls Club of any important changes. I understand that Shabbat Girls Club is a group program and authorize my daughter to participate in its age-appropriate activities.
Parent/Guardian Name: *
Signature: *
Date: *
Pricing:
- For Members: $0 (Free)
- 1 Session: $12
- 5 Sessions : $50
- All Sessions (Oct - May): $180
Payments*

Payment Method*

Credit Card Paypal Venmo or Zelle

Postal / Zip Code

Country

Welcome to Shabbat Girls Club!

We look forward to a wonderful year of friendship, fun, discovery and Jewish pride together.
I would like to receive news and updates by email
Should be Empty:

This page uses TLS encryption to keep your data secure.

Programs