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Child Care for High Holidays 5784
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Child Care Reservations are Required!
Babysitting will be provided during certain service times, free of charge. However, in order to properly staff for our children’s safety, you
must register in advance
. Please complete the form below no later than September 1, 2023. Please note allergies. Ages 1 to 6 years only.
*
First Name (Primary)
*
Last Name (Primary)
*
Email (Primary)
*
Phone (Primary)
*
Street Address (Primary)
Street Address Line 2 (Primary)
*
City (Primary)
*
State (Primary)
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
ZIP (Primary)
*
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Relationship
*
How many children require care during services?
Please Select One
1 Child
2 Children
3 Children
4 Children
*
Child1 First Name
*
Child 1 Last Name
*
Age of Child 1
*
Child 1 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Child 1 Allergy/Medication Details
1
*
Child 2 First Name
*
Child 2 Last Name
*
Age of Child 2
*
Child 2 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Child 2 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
*
Child 3 First Name
*
Child 3 Last Name
*
Age of Child 3
*
Child 3 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Child 3 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
*
Child 4 First Name
*
Child 4 Last Name
*
Age of Child 4
*
Student 4 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Student 4 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
Please select all the services where you will require childcare
Saturday, September 16th Morning 9:00 a.m. - 12:30 p.m.
Sunday, September 17th Morning 9:00 a.m. - 12:30 p.m.
Sunday, September 24th Evening 6:00 p.m. - 8:00 p.m.
Monday, September 25th 9:00 a.m. - 12:30 p.m.
Monday, September 25th 4:30 p.m. - 7:30 p.m.
Mon, May 12 2025 14 Iyyar 5785
