Youth Group Registration 2022-2023

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Youth Group Registration Form
2022-2023

* Is your family a member of Midway Jewish Center?

* For which Youth Group program are you registering your child?

* Child's First Name

* Child's Last Name

* Child's School:

* Grade as of September 2022

* Address

City

State

Zip

* Child's current age

Child's Birthdate

* Child's Gender Identity

Home Phone:

Child's e-mail address:

Child's cell phone:

* Parent 1 e-mail address:

Parent 2 e-mail address

* Would parent(s) like to be on email list?

Emergency Contact(s):

* First Name

* Last Name

* Cell phone:

Alternate contact first name

Alternate contact last name

Alternate contact phone number

* Relationship of Emergency Contact to your child:

* Do you consent to the use of your child's photograph, likeness, or other depiction on the MJC website and/or in other MJC Promotional materials (including social media)?

* Please note any dietary restrictions for your child

(If no restrictions, please write NONE)

Please note any food or other allergies we need to be aware of

(If no allergies, please write NONE)

Thu, April 25 2024 17 Nisan 5784

Youth Group Registration 2022-2023

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