ELC Enrollment Form - Form - Temple Beth Avodah

* Please enter the number of child/ren

Child 1 Enrollment Form

* Child's Name

* Child's Date of Birth

* Primary Language

* Identifying Marks

* Eye Color

* Hair Color

* Skin Color

* Gender

* Height

* Weight

* Allergies/Special Diet

* Does your child have an Individual Health Plan for a chronic health condition?

Please Select OneYes, I will send you a copy as soon as possible.No.

* I will provide a current health Certificate of Immunization & evidence of current physical exam signed by child's pediatrician.

I will contact my child's pediatrician for a current health form and send you a copy ASAP. Physical Exams are valid for one year.

Child 2 Enrollment Form

Child's Name

Child's Date of Birth

Primary Language

Identifying Marks

Eye Color

Hair Color

Skin Color

Gender

Height

Weight

Allergies/Special Diet

Does your child have an Individual Health Plan for a chronic health condition?

Yes, I will send you a copy as soon as possible.No.

I will provide a current health Certificate of Immunization & evidence of current physical exam signed by child's pediatrician.

I will contact my child's pediatrician for a current health form and send you a copy ASAP. Physical exams are valid for one year.

Child 3 Enrollment Form

Child's Name

Child's Date of Birth

Primary Language

Identifying Marks

Eye Color

Hair Color

Skin Color

Gender

Height

Weight

Allergies/Special Diet

Does your child have an Individual Health Plan for a chronic health condition?

Yes, I will send you a copy as soon as possible.No.

I will provide a current health Certificate of Immunization & evidence of current physical exam signed by child's pediatrician.

I will contact my child's pediatrician for a current health form and send you a copy ASAP. Physical exams are valid for one year.

Additional Health Information

* Child(ren)'s Physician (First & Last Name)

* Street Address

* City, State, Zip

* Phone Number

* Are there any custody agreements, court orders and restraining orders pertaining to your child that we should know about?

Please Select OneYes, I will send you a copy as soon as possible.No.

Parent 1 Information

* Parent/Guardian Name (First & Last)

* Relationship to Child

* Street Address

* City, State, Zip

* Home Phone

* Cell Phone

* Email Address

* Business Name

* Business Address

* Business City, State, Zip

* Business Phone Number

* Hours at Work

Parent 2 Information

Parent/Guardian Name (First & Last)

Relationship to Child

Cell Phone

Email Address

Business Name

Business Address

Business City, State, Zip

Business Phone Number

Hours at Work

Parent Signature & Date

* With whom does your child(ren) reside?

* By typing my name below and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.

* Date