Setzer Youth Education Registration Form

Register my child (#1) in the following program*
My child will also participate in:
- Jewish Teen Leadership Initiative (8th - 11th Grade)
- Siyyum (12th Grade)
Child #1 Name*
First Last
Child #1 Gender
Child #1 Email
Child #1 Cell Phone
Child #1 - School Attending
Child #1 T Shirt Size
Child #1 Primary Care Physician & Phone Number
Child #1 Insurance Company
Child #1 Insurance Policy & Group Number
Child #1 Insurance Member Number
Child #1 Insurance Company Phone Number
Child #1 - I give permission for my child to take the following over-the-counter medications under the supervision of the Youth Director or Youth Advisor*
- Acetaminophen
- Ibuprofen
- Antihistamine
Child #1 - Please list any additional information we should be aware of
i.e. allergies, medications, special circumstances, etc.
I have another child to register*
- Yes
- No

Register my child (#2) in the following program
My child (#2) will also participate in:
- Jewish Teen Leadership Initiative (8th - 11th Grade)
- Siyyum (12th Grade)
Child #2 Name
First Last
Child #2 Gender
Child #2 Email
Child #2 Cell Phone
Child # 2 School Attending
Child #2 Grade
Child #2 T Shirt Size
Child #2 Primary Care Physician & Phone Number
Insurance Information is the same as Child #1
- Yes
- No
Child #2 Insurance Company
Child #2 Insurance Policy & Group Number
Child #2 Insurance Member Number
Child #2 Insurance Company Phone Number
Child #2 - I give permission for my child to take the following over-the-counter medications under the supervision of the Youth Director or Youth Advisor
- Acetaminophen
- Ibuprofen
- Antihistamine
Child #2 - Please list any additional information we should be aware of
i.e. allergies, medications, special circumstances, etc.
I have another child to register
- Yes
- No

Register my child (#3) in the following program
My child (#3) will also participate in:
- Jewish Teen Leadership Initiative (8th - 11th Grade)
- Siyyum (12th Grade)
Child #3 Name
First Last
Child #3 Email
Child #3 Cell Phone
Child #3 School Attending
Child #3 Grade
Child #3 T Shirt Size
Child #3 Primary Care Physician & Phone Number
Insurance Company is the same as Child #1 or #2
- Yes
- No
Child #3 Insurance Company
Child #3 Insurance Policy & Group Number
Child #3 Insurance Company Phone Number
Child #3 - I give permission for my child to take the following over-the-counter medications under the supervision of the Youth Director or Youth Advisor
- Acetaminophen
- Ibuprofen
- Antihistamine
Child #3 - Please list any additional information we should be aware of
i.e. allergies, medications, special circumstances, etc.

Parent/Guardian 1 Name
First Last
Parent/Guardian 1 Email Address
Parent/Guardian 1 Preferred Phone Number
Parent/Guardian 1 Cell Number
Parent/Guardian 1 Address
Street Address City State / Province / Region ZIP / Postal Code
Parent/Guardian 2 Name
First Last
Parent/Guardian 2 Email Address
Parent/Guardian 2 Preferred Phone Number
Parent/Guardian 2 Cell Number
Parent/Guardian 2 Address (if different from Parent/Guardian 1)
Street Address City State / Province / Region ZIP / Postal Code

Emergency Contacts
If Parent/Guardian 1 & 2 cannot be reached, please provide the name and phone number of two people who will be responsible for child(ren) registered on this form
Emergency Contact #1 Name
First Last
Emergency Contact #1 Relationship
Emergency Contact #1 Phone Number
Emergency Contact #2 Name
First Last
Emergency Contact #2 Relationship
Emergency Contact #2 Phone Number
Do you authorize the above emergency contacts to advise the school regarding the welfare of your child in the event that you the parent(s)/guardian(s) can not be reached?
Consent Form
I give permission to the Setzer Youth Education program at the Jacksonville Jewish Center to use photographs or videos of my child(ren) registered on this form and/or myself in any publication or advertisement, whether they be in print, video or online.*
I am aware that I will need to complete additional paperwork (Consent, Authorization and Release Form and Code of Conduct Form) that will be sent to me by the Setzer Youth Education Office that must be turned in for my child(ren)'s registration to be finalized.*
I acknowledge that I have filled out the information on this registration form to the best of my abilities and will update the Setzer Youth Education Office of any changes as they occur*
Total charges for registration for my child(ren)
$0.00
This is a calculation of all of the Setzer Youth Programs that you chose on the first pages.
Payment*
Credit Card

Card Details

Cardholder Name

Emergency Contacts