2016-17 RELIGIOUS SCHOOL & YOUTH GROUP REGISTRATION FORM

PLEASE COMPLETE ALL FIELDS. When you click the SUBMIT button, your information will be sent to the Addison M. & Elizabeth Opper Religious School Office for processing.

Please remember to fill out the two other required forms which, can be downloaded here: Code of Conduct Form & Photo & Trip Release Form.


Address *
Address
Phone *
Phone
Birth Date *
Birth Date
INFORMATION ON SIBLINGS
Child 1 Name
Child 1 Name
Child 1 Birth Date
Child 1 Birth Date
Child 2 Name
Child 2 Name
Child 2 Birth Date
Child 2 Birth Date
Child 3 Name
Child 3 Name
Child 3 Birth Date
Child 3 Birth Date
PARENTS
Father's Name *
Father's Name
Father's Cell Phone *
Father's Cell Phone
Father's Business Phone
Father's Business Phone
Mother's Name *
Mother's Name
Mother's Cell Phone *
Mother's Cell Phone
Mother's Business Phone
Mother's Business Phone
MEDICAL INFORMATION
EMERGENCY INFORMATION
If Parents cannot be reached for an emergency, please call:
Name 1 *
Name 1
Name 1 Phone
Name 1 Phone
Name 2
Name 2
Name 2 Phone
Name 2 Phone
Doctor's Name
Doctor's Name
Doctor's Phone
Doctor's Phone
INSURANCE
NOTE ON AUTHORIZATION FORM:
The authorization granted by this form will be used only after efforts have been made to contact the parent(s) listed above.
MEDICAL AND / OR SURGICAL TREATMENT
In the event that my child,
requires medical care and/or treatment, I hereby authorize Beth Rishon and the doctors and/or hospital selected by it to take and to perform all procedures which are deemed necessary, and render any indicated treatment, including the administration of anesthesia, if needed, and the performance of an operation, if in the opinion of said doctor(s) the same necessary. I hereby release Beth Rishon from any liability arising out of its use of the reliance on this authorization.
* By checking this box and typing my name below, I am electronically signing this form. *
Date 4 *
Date 4
Child's Name *
Child's Name
Address
Address