CRJ Early Learning Center Registration 2023

Early Learning Center Registration

2023/5783
Toddlers for children who turn 18 months by December 1, 2022
Twos for children who turn 2 by September 1, 2022
Threes for children who turn 3 by September 1, 2022

If you have any questions when filling out this registration form please contact Amanda Jacobs at 407-645-0444 or ajacobs@crjorlando.org.

* Which class are you interested enrolling your child into? (Deposit Only Required at this time)

Please Choose OneToddlers - $300.00Twos - $300.00Threes - $300.00

* Are you interested in full time or part time?

Full TimePart Time

Home Phone where child resides (if parents do not live together)

* Parent 1 First Name

* Parent 1 Last Name

* Paren 1 Email

Parent 1 Work Phone

Parent 1 Cell

* Parent 2 First Name

* Parent 2 Last Name

Parent 2 Email

Parent 2 Work Phone

* Parent 2 Mobile

* Home Address

* City

* State

* Zip

* Child's First Name

* Child's Last Name

Child's Nickname

* Child's Date of Birth

* Child's Gender

* Emergency Contact Name

Please name OTHER than parents.

* Emergency Contact Phone

* Relationship to Child

Allergies/Unique Needs/What other information should we know about your child to help ensure the best possible experience possible?

If parents are divorced or separated, with whom does child reside?

Do you want mailings to be sent to both parents?

**Please indicate 2nd address, applies only if parents do not reside in the same house

* This is to certify that my child has my permission to participate in all activities that are part of CRJ ELC. If there are any restrictions please list:

Please initial

* Health Insurance Company and Policy Number

* Primary Physician's Name and Phone

Activity and Photo Release

I hereby give permission for myself and my family to participate in all activities of the Congregation of Reform Judaism (CRJ). The undersigned, individually and as legal guardian(s), hereby release the Congregation of Reform Judaism, Inc. its agents, representatives and employees for any acts or omissions which cause or result in injury at any events held at CRJ or at any outings, or going to and from outings, irrespective of cause. Furthermore, CRJ is given express authority to seek and obtain at our expense any and all emergency medical treatment for and on behalf of the undersigned and my family members for all injuries sustained.

I grant the Congregation of Reform Judaism (CRJ), its representatives and employees the right to take photographs of me (and my family and guests), and authorize CRJ, its assigns and transferees to copyright, use the photographs in its promotional and marketing material and publicity efforts. I hereby hold harmless and release CRJ, its representatives and employees from liability for any violation of any personal or proprietary right it may have in connection with such use. I agree that CRJ may use such photographs of me with or without my name and for any lawful purpose, including print and/or electronic usage.

* Please initial below to indicate you and you agree to the above Photo & Activity Release

Wed, October 4 2023 19 Tishrei 5784