JMC Registration 2024-2025 - Form - Congregation Or Atid

Section A: Family Contact Information

* First Name (Primary)

* Last Name (Primary)

* Email (Primary)

* Phone (Primary)

* Relationship to Student(s) (Primary)

* Street Address (Primary)

Street Address Line 2 (Primary)

* City (Primary)

* State (Primary)

* ZIP (Primary)

* Is there a secondary contact?

Please Select OneNoYes, at the same address as the primary contactYes, at a different address than the primary contactIf there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first

* First Name (Secondary)

* Last Name (Secondary)

* Email (Secondary)

* Phone (Secondary)

* Relationship to Student(s) (Secondary)

* Street Address (Secondary)

Street Address Line 2 (Secondary)

* City (Secondary)

* State (Secondary)

* ZIP (Secondary)

* Emergency Contact Name ( if other than parent )

* Emergency Contact Phone ( if other than parent )

* Emergency Contact Relationship ( if other than parent )

* 2nd Emergency Contact Name ( if other than parent )

* 2nd Emergency Contact Phone ( if other than parent )

* 2nd Emergency Contact Relationship ( if other than parent )

Section B: Student Enrollment Information

* How many children are being enrolled for the 2023/2024 school year?

Please Select One1 Child2 Children3 Children

Student 1 Information

* Student 1 First Name

* Student 1 Last Name

* Student 1 Birthdate

* Student 1 English spelling of Hebrew name

Student 1 Nickname (if applicable)

* Student 1 Grade

Name of School your child attends

* Does your child have any special learning needs the school should know about?

Please Select OneNoYesIf yes, we would love to speak with you before the program begins so that we are able to discuss the best ways to support your child from the outset.

* Are your child's immunizations up to date?

Please Select OneNoYes

* Are there any allergies or medications we need to know about?

Please Select OneNoYes

Student 1 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Student 2 Information

* Student 2 First Name

* Student 2 Last Name

* Student 2 Birthdate

* Student 2 English spelling of Hebrew name

Student 2 Nickname (if applicable)

* Student 2 Grade

Name of School your child attends

* Does your child have any special learning needs the school should know about?

Please Select OneNoYesIf yes, we would love to speak with you before the program begins so that we are able to discuss the best ways to support your child from the outset.

* Are your child's immunizations up to date?

Please Select OneNoYes

* Are there any allergies or medications we need to know about?

Please Select OneNoYes

Student 2 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Student 3 Information

* Student 3 First Name

* Student 3 Last Name

* Student 3 Birthdate

* Student 3 English spelling of Hebrew name

Student 3 Nickname (if applicable)

* Student 3 Grade

Name of School your child attends

* Does your child have any special learning needs the school should know about?

Please Select OneNoYesIf yes, we would love to speak with you before the program begins so that we are able to discuss the best ways to support your child from the outset.

* Are your child's immunizations up to date?

Please Select OneNoYes

* Are there any allergies or medications we need to know about?

Please Select OneNoYes

Student 3 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Section C: Release Forms

By signing my name below, I give my child(ren) permission to participate in the Jewish Middle School Community (JMC), a program sponsored, in part, by generous contribution from the Jewish Community Federation of Richmond and is supported by Congregation Or Atid. In consideration of my child(ren)'s enrollment as a student in the JMC program, I hereby waive any and all claims against Congregation Or Atid, its agents and its employees that may arise out of any injury, loss or damage suffered by my child(ren) during any program activity. I give permission for my contact information to be distributed in a JMC roster.

* Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Medical Release

In case of injury or illness of a child at JMC programs, every effort will be made to contact a parent or guardian. The following instructions will remain in force, unless revoked by a parent or guardian.

* If injury or illness is minor, can we give your child first aid?

Please Select OneYesNo

* If injury is serious and parent cannot be contacted, may we contact your child's physician or dentist?

Please Select OneYesNoPlease provide contacts below

* Do we have your permission to call an ambulance?

Please Select OneYesNo

* Do we have your permission to give Tylenol or Motrin?

Please Select OneYesNo

* Physician's Name

* Telephone

* Dentist's Name

* Telephone

At the time of submission, I certify that my child(ren) is(are) in good physical health.

* Medical Release: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Field Trip Agreement

I give my child(ren) permission to participate in field trips organized by Jewish Middle School Community (JMC), a program sponsored, in part, by generous contribution from the Jewish Community Federation of Richmond and is supported by Congregation Or Atid.
I understand that they will travel by parent provided/coordinated transportation or private car, and will be accompanied by staff and parent chaperons.

Field Trip Agreement: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Media Release

From time to time your child’s photo may be taken in our classrooms or special events. We use these photos in the synagogue newsletter, on our synagogue display boards, the COA website as well as private Facebook groups and other publicity materials.

* I give my permission for my child(ren)'s photo to be used:

Please Select OneOn any materialsOn specific materials with my permissionI do not give my permission for my child’s image to be used

Section D: Congregation Community

Would you be interested in volunteering for program events?

Volunteer Opportunities (check all that apply)

I am am able to help at events at times, in generalCarpool: I would be happy to offer a ride to participants that live near me occasionallyI am a teacher, and would be happy to help in this way as wellI am open to possibly hosting (an) event(s)I am able to volunteer in other ways. Please list any and all skills or ways you can help

If you chose the "other" option please specify here

Section E: Preferencces

Which days & times would work for your child(ren) to participate ( please be as flexible as possible. check all the apply )

Sundays 3:30-5:30 PMPrefer weekdays, please list each weekdays and the time ranges available for each day of the week availablePrefer other, please clarify any details here

If you chose weekday or other option please specify here

Are you available for carpool occasionally?

Yes, I or someone in our family, can be available to take 1 or more kids occasionallyMy kid(s) are likely to need a ride to most events, to participate Other ( Please clarify in the text box )

If you chose "Other" option please clarify here