Netivon Registration 2020-2021

Welcome to the Netivon 2020-2021 Registration Form!

Thank you for your interest in Netivon! Please complete the following registration form.

Pricing for the 2020-2021 year is $1,030 for members of Chizuk Amuno and $1,435 for all other students (this includes the non-member security surcharge). The balance will be charged to your synagogue account on July 1, 2020 (or immediately following registration, if past this date).

If you would prefer to pay by check, please complete and print the form and return it, along with your deposit, to:

Attn: Netivon
8100 Stevenson Road
Baltimore, MD 21208

If you have any questions, whether about the program or registration process itself, please contact Ethan Haas at (410) 486-8641 or ehaas@chizukamuno.org.

Student #1 Name*

First Last

Student #1 Hebrew Name

Hebrew Name

Student #1 Program Selection*

Student #1 Birthday*

MM

DD

YYYY

Student #1 Gender*

Male
Female

Student #1 Day School*

Student #1 Health/Dietary Concerns*

No, my student does not have any health/dietary concerns.
Yes, my student has health/dietary concerns.

Please use the space below to explain your student's health/dietary concerns.*

Are you interested in enrolling another student in Netivon today?*

No
Yes

Student #2 Name*

First Last

Student #2 Hebrew Name*

Hebrew Name

Student #2 Program Selection*

Student #2 Birthday*

MM

DD

YYYY

Student #2 Gender*

Male
Female

Student #2 Day School*

Student #2 Health/Dietary Concerns*

No, my student does not have any health/dietary concerns.
Yes, my student has health/dietary concerns.

Please use the space below to explain your student's health/dietary concerns.*

Primary Address*

Street Address Address Line 2 City State ZIP Code

Do you have a secondary mailing address?*

No, I only use the primary address above.
Yes, I have a secondary mailing address.

Secondary Mailing Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

What is your current synagogue affiliation status?*

Member of Chizuk Amuno
Member of another synagogue
Unaffiliated with any synagogue

With which synagogue are you affiliated?*

Would you like someone to contact you regarding membership at Chizuk Amuno?*

No thanks, I am not interested in membership at this time.
Yes, please have someone contact me regarding Chizuk Amuno membership.

Parent #1 Name*

First Last

Parent #1 Email*

Parent #1 Cell Phone*

Parent #1 Work Phone

Parent #2 Name

First Last

Parent #2 Email

Parent #2 Cell Phone

Parent #2 Work Phone

Emergency Contact Name*

First Last

Emergency Contact Phone*

Photo Authorization*

I hereby authorize Chizuk Amuno Congregation to use print and digital pictures and videos of my child(ren), taken at Chizuk Amuno Congregation events, in print and digital publicity and marketing for Chizuk Amuno Congregation and Netivon. I understand that my child's full name will NEVER appear next to his or her picture and the pictures will be used exclusively to promote Chizuk Amuno Congregation and Netivon or for educational materials.

Yes, I authorize the above.
No, I do not authorize the above.

Field Trip Permission*

I hereby grant my permission for my child(ren) to attend any programs or field trips off-site during regular Netivon hours and to take any transportation required to attend these trips. I understand that I will be notified in advance of any off-site programs or field trips applicable to my child(ren) so that I will know his/her whereabouts at all times.

Yes, I grant permission for my student to attend field trips.
No, my student is not permitted to attend field trips.

Electronic Signature*

By typing my name, I affirm that all information on this form is accurate to the best of my knowledge and that I am making a commitment to Netivon for the 2020-2021 year.

First Last

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Netivon Registration 2020-2021

Welcome to the Netivon 2020-2021 Registration Form!