Shabbos Afternoon Youth Center

* First Name

* Last Name

PARENT/GUARDIAN INFORMATION

* First Name

* Last Name

* Phone

* Email

* Relationship

Other Guardian First Name

Other Guardian Last Name

Other Phone

Other Email

Other Relationship

Home Address

CHILD-1 INFORMATION

Child-1 First Name

Child-1 Last Name

Gender

Grade

School

Date of Birth

Child-1 Phone

Child-1 Email

CHILD-2 INFORMATION

Child-2 First Name

Child-2 Last Name

Gender

Grade

School

Date of Birth

Child-2 Phone

Child-2 Email

CHILD-3 INFORMATION

Child-3 First Name

Child-3 Last Name

Gender

Grade

School

Date of Birth

Child-3 Phone

Child-3 Email

CHILD-4 INFORMATION

Child-4 First Name

Child-4 Last Name

Gender

Grade

School

Date of Birth

Child-4 Phone

Child-4 Email

COMMITMENT TO COMBAT COVID-19

* Check here to indicate that you and your family agree to adhere to the COVID-19 Guidelines

Check here to indicate that you and your family agree to adhere to the COVID-19 GuidelinesChecking the box above indicates that you will instruct your children to do the following:

WEAR A MASK AT ALL TIMES
STAY IN DESIGNATED GROUP LOCATION
DO NOT BRING ANY FOOD OR DRINK FROM HOME
SANITIZE HANDS WHEN INSTRUCTED
STAY HOME IF SICK OR LEGALLY MANDATED TO QUARANTINE DUE TO EXPOSURE OR TRAVEL

* Fee for ...

Please Select OneOne Family for $375Sponsorship ( includes one family) $1,800

Thu, April 25 2024 17 Nisan 5784

West Side Institutional Synagogue • 120 West 76th Street • New York, NY 10023
Tel: 212-877-7652 • Fax: 212-877-9333 • Email: office@wsisny.org