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 Date of Birth*
Date Format: MM slash DD slash YYYY
Child #1 Email
Child #1 Cell Phone
Child #1 School Attending*
Child #1 Grade*
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 of which we should be aware. If none, please write n/a.*
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 Date of Birth*
Date Format: MM slash DD slash YYYY
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 of which we should be aware. If none, please write n/a.
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 Date of Birth*
Date Format: MM slash DD slash YYYY
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 of which we should be aware. If none, please write n/a.*
i.e. allergies, medications, special circumstances, etc.
I have another child to register*
- Yes
- No

Register my child (#4) in the following program*
My child (#4) will also participate in:
- Jewish Teen Leadership Initiative (8th - 11th Grade)
- Siyyum (12th Grade)
Child #4 Name*
First Last
Child # 4 Date of Birth*
Date Format: MM slash DD slash YYYY
Child #4 Email
Child #4 Cell Phone
Child #4 School Attending*
Child #4 Grade*
Child #4 T Shirt Size*
Child #4 Primary Care Physician & Phone Number*
Insurance Company is the same as Child #1 or #2 or #3*
- Yes
- No
Child #4 Insurance Company
Child #4 Insurance Policy & Group Number
Child #4 Insurance Company Phone Number
Child #4 - 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 #4 Please list any additional information of which we should be aware. If none, please write n/a.*
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

Cardholder Name

Card Details

Emergency Contacts