2021-2022 CBY Youth Group Child Registration - Form

In anticipation of a robust and full opening of groups at the beginning of the 2021 school year we are asking all parents to fill out the form below, for each child they will be sending to groups this year. This information is critical to ensure that your child has a safe, secure, and wonderful experience in shul. Please complete this form no later than August 15th, as this will help us prepare for the coming year ahead.

As a reminder, in accordance with medical guidelines, all unvaccinated individuals, including children, must wear a mask indoors.
We look forward to a wonderful year filled with davening, fun, games, and so much more!
As always, if you have any questions, please do not hesitate to reach out to us at youth@bnaiyeshurun.org.

Thank you for your cooperation!

Yehoshua & Rivka Szafranski

* Family Last Name:

* Mother's First Name:

* Mother's best contact phone #:

* Mother's best contact email:

What minyan does mother typically attend at CBY on Shabbat morning?

Where can you be found if there are any issues that arise for your child?

If "Other", please explain:

* Father's First Name:

* Father's Last Name:

* Father's best contact phone #:

* Father's best contact email:

What minyan does father typically attend at CBY on Shabbat morning?

Where can you be found if there are any issues that arise for your child?

If "Other", please explain:

* Are there any other caretakers who will be bringing your child/children to groups on a regular basis? (i.e. a grandparent)

Please indicate yes or no:Yes (If yes, please list in the adjacent field)No

Please list the full name, contanct information, phone number and minyan attending of caretaker:

* How many children will you be registering for goups? (Nursery through Grade 6)

Child's First Name:

Child's Last Name:

Child's Age

Child's Grade as of September 2021:

* Does your child have any allergies?

Please Select OneYes (Please list in the adjacent field)No

Please list any allergies:

* Does your child cary an EpiPen?

Please Select OneYes, (Please indicate its location during groups in the adjacent field)No

Where will the EpiPen be when your child comes to groups?

Are there any other medical conditions you would like us to be aware of about your child?

Are there any social/emotional issues we should be aware of about your child?

Anything else you would like us to know about your child's groups' attendance?

Child's First Name:

Child's Last Name:

Child's Age

Child's Grade as of September 2021:

* Does your child have any allergies?

Please Select OneYes (Please list in the adjacent field)No

Please list any allergies:

* Does your child cary an EpiPen?

Please Select OneYes, (Please indicate its location during groups in the adjacent field)No

Where will the EpiPen be when your child comes to groups?

Are there any other medical conditions you would like us to be aware of about your child?

Are there any social/emotional issues we should be aware of about your child?

Anything else you would like us to know about your child's groups' attendance?

Child's First Name:

Child's Last Name:

Child's Age

Child's Grade as of September 2021:

* Does your child have any allergies?

Please Select OneYes (Please list in the adjacent field)No

Please list any allergies:

* Does your child cary an EpiPen?

Please Select OneYes, (Please indicate its location during groups in the adjacent field)No

Where will the EpiPen be when your child comes to groups?

Are there any other medical conditions you would like us to be aware of about your child?

Are there any social/emotional issues we should be aware of about your child?

Anything else you would like us to know about your child's groups' attendance?

Child's First Name:

Child's Last Name:

Child's Age

Child's Grade as of September 2021:

* Does your child have any allergies?

Please Select OneYes (Please list in the adjacent field)No

Please list any allergies:

* Does your child cary an EpiPen?

Please Select OneYes, (Please indicate its location during groups in the adjacent field)No

Where will the EpiPen be when your child comes to groups?

Are there any other medical conditions you would like us to be aware of about your child?

Are there any social/emotional issues we should be aware of about your child?

Anything else you would like us to know about your child's groups' attendance?

Child's First Name:

Child's Last Name:

Child's Age

Child's Grade as of September 2021:

* Does your child have any allergies?

Please Select OneYes (Please list in the adjacent field)No

Please list any allergies:

* Does your child cary an EpiPen?

Please Select OneYes, (Please indicate its location during groups in the adjacent field)No

Where will the EpiPen be when your child comes to groups?

Are there any other medical conditions you would like us to be aware of about your child?

Are there any social/emotional issues we should be aware of about your child?

Anything else you would like us to know about your child's groups' attendance?