LIBERTY December Lock-in Registration for Non-LIBERTY Members

Please fill out this form to register as a NON-LIBERTY member for the December Lock-In on December 13, 2019.

Parent Information

* Parent Name

* Parent 1 Email

* Parent 1 Cell Phone

Youth Information

* Child's Full Name

* Child Date of Birth

* Child's Grade

Publications and Photos/Videos

Temple Beth El may publish individual photos/videos of your child(ren) in Temple Beth El publications, in CJN or other newspapers, on the website, or other social media with secure and restricted public access, and on school bulletin boards. If you DO NOT wish to have your child's photograph published, please check this box. Note: All students may appear in photos/videos that showcase whole classes or multiple student groups.

Children's Medical Information and Release

Your answers are held in complete confidence with the Director of Education. Being as honest and thorough as possible allows us to provide the best environment for your child(ren).

Please list all allergies or foods that must be avoided

Any special medical concerns (allergies, medications, etc.) should we know about?

Please describe any special needs your child has

If you are registering more than one child, please indicate which child you are referring to.

PERMISSION FOR EMERGENCY MEDICAL TREATMENT

* Name of Child(ren)'s Physician

* Physician Phone Number(s)

* Insurance Carrier

* Insurance Policy Number

* Name of Insurance Policy Holder

I/we will indemnify, save harmless and defend Temple Beth El, its officers, directors, agents, and employees, from all liability from loss, damage, or injury to persons or property in any manner arising out of or incident to the performance of this agreement including without limitation all consequential damages and/or attorney's fees. in the event of a medical emergency and I/we cannot be reached, I/we hereby give permission to the physician selected by the Temple agent to hospitalize and secure proper treatment for my child(ren) as named herein.

* Parent/Guardian E-Signature

In the event your child becomes ill or injured and we are unable to reach a parent, please provide two emergency contacts (one of these could be a 2nd parent of guardian). We will always attempt to reach parents first.

* Emergency Contact 1 Name

* Emergency Contact 1 Relationship

* Emergency Contact 1 Phone Number

* Emergency Contact 2 Name

* Emergency Contact 2 Relationship

* Emergency Contact 2 Phone Number

* Number of Children you are registering for $40 each

Tue, April 23 2024
15 Nisan 5784

Tue, April 23 2024 15 Nisan 5784