Shabbat Girls Club - 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 Name She Likes to Be Called: * Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year 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 During Shabbat Girls Club, photographs may occasionally be taken for Chabad Waterways communications 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: * 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 Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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